Editorial Notes
Amendments
2020—Subsec. (c)(1). Pub. L. 116–136, § 3708(d)(1), struck out “(provided under section 1395u(r) of this title)” after “unique identifier” and inserted “the nurse practitioner or clinical nurse specialist (as those terms are defined in section 1395x(aa)(5) of this title), or the physician assistant (as defined in section 1395x(aa)(5) of this title)” after “physician”.
Subsec. (e)(1)(A). Pub. L. 116–136, § 3708(d)(2)(A), inserted “a nurse practitioner or clinical nurse specialist, or a physician assistant” after “physician”.
Subsec. (e)(2). Pub. L. 116–136, § 3708(d)(2)(B), substituted “Rule of construction regarding requirement for certification” for “Physician certification” in heading and struck out “physician” before “certification” in text.
2018—Subsec. (b)(2). Pub. L. 115–123, § 51001(a)(1), inserted subpar. (A) designation and heading before “In defining” and added subpar. (B).
Subsec. (b)(3)(A)(iv). Pub. L. 115–123, § 51001(a)(2)(A), added cl. (iv).
Subsec. (b)(3)(B)(iii). Pub. L. 115–123, § 53110(1), inserted “and for 2020 shall be 1.5 percent” after “1 percent”.
Subsec. (b)(3)(B)(vi)(I). Pub. L. 115–123, § 53110(2), inserted “and 2020” after “except 2018”.
Subsec. (b)(3)(D). Pub. L. 115–123, § 51001(a)(2)(B), added subpar. (D).
Subsec. (b)(4)(B). Pub. L. 115–123, § 51001(a)(3), inserted cl. (i) designation and heading before “The Secretary” and added cl. (ii).
Subsec. (c)(3). Pub. L. 115–123, § 50208(a)(2), added par. (3).
2015—Subsec. (b)(3)(B)(iii). Pub. L. 114–10, § 411(c)(1), inserted at end “Notwithstanding the previous sentence, the home health market basket percentage increase for 2018 shall be 1 percent.”
Subsec. (b)(3)(B)(vi)(I). Pub. L. 114–10, § 411(c)(2), inserted “(except 2018)” after “each subsequent year”.
2014—Subsec. (b)(3)(B)(v)(I). Pub. L. 113–185, § 2(c)(1)(A), substituted “subclauses (II) and (IV)” for “subclause (II)”.
Subsec. (b)(3)(B)(v)(II). Pub. L. 113–185, § 2(c)(1)(B), substituted “Subject to subclause (V), for 2007” for “For 2007”.
Subsec. (b)(3)(B)(v)(III). Pub. L. 113–185, § 2(c)(1)(C), inserted “and subclause (IV)(aa)” after “subclause (II)”.
Subsec. (b)(3)(B)(v)(IV), (V). Pub. L. 113–185, § 2(c)(1)(D), added subcls. (IV) and (V).
2010—Subsec. (b)(3)(A)(i)(III). Pub. L. 111–148, § 3131(a)(1)(A), substituted “Subject to clause (iii), for periods” for “For periods”.
Subsec. (b)(3)(A)(iii). Pub. L. 111–148, § 10315(a), substituted “2014” for “2013” in heading and in subcl. (I), and “2017” for “2016” in subcl. (II).
Pub. L. 111–148, § 3131(a)(1)(B), added cl. (iii).
Subsec. (b)(3)(B)(ii)(V). Pub. L. 111–148, § 3401(e)(1), substituted “clauses (v) and (vi)” for “clause (v)”.
Subsec. (b)(3)(B)(vi). Pub. L. 111–148, § 3401(e)(2), added cl. (vi).
Subsec. (b)(3)(B)(vi)(II). Pub. L. 111–148, § 10319(d), substituted “, 2012, and 2013” for “and 2012”.
Subsec. (b)(3)(C). Pub. L. 111–148, § 3131(b)(1), substituted “5 percent of the total payments estimated to be made based on the prospective payment system under this subsection for the period.” for “the aggregate increase in payments resulting from the application of paragraph (5) (relating to outliers).”
Subsec. (b)(5). Pub. L. 111–148, § 3131(b)(2), designated existing provisions as subpar. (A), inserted heading, substituted “Subject to subparagraph (B), the Secretary” for “The Secretary” and “2.5 percent” for “5 percent”, and added subpar. (B).
2006—Subsec. (b)(3)(B)(ii)(III). Pub. L. 109–171, § 5201(a)(1), substituted “all of 2005” for “each of 2005 and 2006”.
Subsec. (b)(3)(B)(ii)(IV). Pub. L. 109–171, § 5201(a)(2), (4), added subcl. (IV). Former subcl. (IV) redesignated (V).
Pub. L. 109–171, § 5201(a)(3), struck out “2007 and” before “any subsequent year”.
Subsec. (b)(3)(B)(ii)(V). Pub. L. 109–171, § 5201(a)(3), (c)(1), redesignated subcl. (IV) as (V) and inserted “subject to clause (v),” after “subsequent year,”.
Subsec. (b)(3)(B)(v). Pub. L. 109–171, § 5201(c)(2), added cl. (v).
2003—Subsec. (b)(3)(B)(i). Pub. L. 108–173, § 701(a)(1), substituted “fiscal year 2002 and for fiscal year 2003 and for each subsequent year (beginning with 2004)” for “each fiscal year (beginning with fiscal year 2002)” and inserted “or year” after “the fiscal year”.
Subsec. (b)(3)(B)(ii)(I). Pub. L. 108–173, § 701(a)(2)(A), struck out “or” at end.
Subsec. (b)(3)(B)(ii)(II). Pub. L. 108–173, § 701(b)(1), struck out “or” at end.
Pub. L. 108–173, § 701(a)(2)(D), added subcl. (II). Former subcl. (II) redesignated (III).
Subsec. (b)(3)(B)(ii)(III). Pub. L. 108–173, § 701(b)(4), added subcl. (III). Former subcl. (III) redesignated (IV).
Pub. L. 108–173, § 701(a)(2)(B), (C), redesignated subcl. (II) as (III) and substituted “2004 and any subsequent year” for “any subsequent fiscal year”.
Subsec. (b)(3)(B)(ii)(IV). Pub. L. 108–173, § 701(b)(2), (3), redesignated subcl. (III) as (IV) and substituted “2007” for “2004”.
Subsec. (b)(3)(B)(iii). Pub. L. 108–173, § 701(a)(3), inserted “or year” after “fiscal year” wherever appearing.
Subsec. (b)(3)(B)(iv). Pub. L. 108–173, § 701(a)(4), inserted “or year” after “fiscal year” wherever appearing and “or years” after “fiscal years”.
Subsec. (b)(5). Pub. L. 108–173, § 701(a)(5), inserted “or year” after “fiscal year”.
2000—Subsec. (b)(3)(A)(i)(II). Pub. L. 106–554, § 1(a)(6) [title V, § 501(a)(3)], added subcl. (II). Former subcl. (II) redesignated (III).
Subsec. (b)(3)(A)(i)(III). Pub. L. 106–554, § 1(a)(6) [title V, § 501(a)(1), (2)], redesignated subcl. (II) as (III) and substituted “described in subclause (II)” for “described in subclause (I)”.
Subsec. (b)(3)(B)(iv). Pub. L. 106–554, § 1(a)(6) [title V, § 501(c)(1)], added cl. (iv).
Subsec. (e). Pub. L. 106–554, § 1(a)(6) [title V, § 504], added subsec. (e).
1999—Subsec. (b)(1). Pub. L. 106–113, § 1000(a)(6) [title III, § 321(k)(19)], made technical amendment to reference in original act which appears in text as reference to August 5, 1997.
Subsec. (b)(3)(A)(i). Pub. L. 106–113, § 1000(a)(6) [title III, § 302(b)], amended heading and text of cl. (i) generally. Prior to amendment, text read as follows: “Under such system the Secretary shall provide for computation of a standard prospective payment amount (or amounts). Such amount (or amounts) shall initially be based on the most current audited cost report data available to the Secretary and shall be computed in a manner so that the total amounts payable under the system for fiscal year 2001 shall be equal to the total amount that would have been made if the system had not been in effect but if the reduction in limits described in clause (ii) had been in effect. Such amount shall be standardized in a manner that eliminates the effect of variations in relative case mix and wage levels among different home health agencies in a budget neutral manner consistent with the case mix and wage level adjustments provided under paragraph (4)(A). Under the system, the Secretary may recognize regional differences or differences based upon whether or not the services or agency are in an urbanized area.”
Subsec. (b)(3)(A)(i)(I). Pub. L. 106–113, § 1000(a)(6) [title III, § 303(b)(1)], which directed that the second sentence of cl. (i) be amended in subcl. (I) by the insertion of “and if section 1395x(v)(1)(L)(ix) of this title had not been enacted” before semicolon, was executed by making the insertion before the period at end of subcl. (I) to reflect the probable intent of Congress.
Subsec. (b)(3)(A)(i)(II). Pub. L. 106–113, § 1000(a)(6) [title III, § 303(b)(2)], inserted “and if section 1395x(v)(1)(L)(ix) of this title had not been enacted” after “if the system had not been in effect”.
Subsec. (b)(3)(B)(ii)(I). Pub. L. 106–113, § 1000(a)(6) [title III, § 306], substituted “each of fiscal years 2002 and 2003” for “fiscal year 2002 or 2003”.
1998—Subsec. (a). Pub. L. 105–277, § 5101(c)(1)(A), substituted “for portions of cost reporting periods occurring on or after October 1, 2000” for “for cost reporting periods beginning on or after October 1, 1999”.
Subsec. (b)(3)(A)(i). Pub. L. 105–277, § 5101(c)(1)(B)(i), substituted “fiscal year 2001” for “fiscal year 2000”.
Subsec. (b)(3)(A)(ii). Pub. L. 105–277, § 5101(c)(1)(B)(ii), substituted “September 30, 2000” for “September 30, 1999”.
Subsec. (b)(3)(B)(i). Pub. L. 105–277, § 5101(d)(2)(A), substituted “home health applicable increase percentage (as defined in clause (ii))” for “home health market basket percentage increase”.
Pub. L. 105–277, § 5101(c)(1)(B)(iii), substituted “fiscal year 2002” for “fiscal year 2001”.
Subsec. (b)(3)(B)(ii), (iii). Pub. L. 105–277, § 5101(d)(2)(B), (C), added cl. (ii) and redesignated former cl. (ii) as (iii).
Statutory Notes and Related Subsidiaries
Effective Date of 1999 Amendment
Amendment by section 1000(a)(6) [title III, § 303(b)] of Pub. L.106–113 applicable to services furnished by home health agencies for cost reporting periods beginning on or after Oct. 1, 1999, see section 1000(a)(6) [title III, § 303(c)] of Pub. L. 106–113, set out as a note under section 1395x of this title.
Amendment by section 1000(a)(6) [title III, § 321(k)(19)] of Pub. L. 106–113 effective as if included in the enactment of the Balanced Budget Act of 1997, Pub. L. 105–33, except as otherwise provided, see section 1000(a)(6) [title III, § 321(m)] of Pub. L. 106–113, set out as a note under section 1395d of this title.
Effective Date
Pub. L. 105–33, title IV, § 4603(d), Aug. 5, 1997, 111 Stat. 471, as amended by Pub. L. 105–277, div. J, title V, § 5101(c)(2), Oct. 21, 1998, 112 Stat. 2681–914, provided that:
“Except as otherwise provided, the amendments made by this section [enacting this section and amending sections 1395f, 1395g, 1395k, 1395l, 1395u, and 1395y of this title] shall apply to portions of cost reporting periods occurring on or after October 1, 2000.”
Increasing Transparency for Home Health Payments Under the Medicare Program
Pub. L. 117–328, div. FF, title IV, § 4142, Dec. 29, 2022, 136 Stat. 5929, provided that:
“(a) Transparency.—In notice and comment rulemaking used to implement section 1895(b)(3)(D) of the Social Security Act (42 U.S.C. 1395fff(b)(3)(D)[)], the Secretary of Health and Human Services (referred to in this section as the ‘Secretary’) shall, on the date of the notice of proposed rulemaking, make available through the internet website of the Centers for Medicare & Medicaid Services the following:
“(1)
Electronic data files showing the Centers for Medicare & Medicaid Services simulation of 60-day episodes under the home health prospective payment system in effect prior to the Patient Driven Groupings Model using data from 30-day periods paid under such Model, if such data are used in determining payment adjustments under clauses (ii) or (iii) of such section 1895(b)(3)(D).
“(2)
To the extent practicable, a description of actual behavior changes, as described in clause (i) of such section 1895(b)(3)(D), including behavior changes as a result of the implementation of sections 1895(b)(2)(B) and 1895(b)(4)(B) of the
Social Security Act (
42 U.S.C. 1395fff(b)(2)(B) and 1395(b)(4)(B) [probably should be “1395fff(b)(4)(B)”]) that occurred in calendar years 2020 through 2026.
“(b) Engagement With Stakeholders.—
“(1) In general.—
Not later than 90 days after the date of enactment of this section [
Dec. 29, 2022], the
Secretary shall use an open door forum, a town hall meeting, a web-based forum, or other
appropriate mechanism to receive input from home health stakeholders and interested parties on
Medicare home health payment rate development, including the items described in paragraphs (1) and (2) of subsection (a) with respect to the home health prospective payment system rate for calendar year 2023.
“(2) Requirement.—
At least 30 days before the forum, meeting, or other mechanism referred to in paragraph (1), the
Secretary shall make available through the internet website of the Centers for
Medicare & Medicaid Services the items described in paragraphs (1) and (2) of subsection (a) with respect to the home health prospective payment system rate for calendar year 2023 as finalized in the final rule entitled ‘
Medicare Program; Calendar Year [(CY)] 2023 Home Health Prospective Payment System Rate Update; Home Health Quality Reporting Program Requirements; Home Health Value-Based Purchasing Expanded Model Requirements; and
Home Infusion Therapy Services Requirements’ published in the Federal Register on
November 4, 2022 (
87 Fed. Reg. 66790).
“(c) Construction.—
Nothing in this section shall be construed to require any change in the methodology used by the
Secretary to implement such section 1895(b)(3)(D), to restrict the
Secretary’s discretion in establishing the methodology to implement such section, or to suggest that the
Secretary’s promulgation of the methodology implementing such Calendar Year 2023 home health final rule was inadequate under
Chapter 5 of title 5,
United States Code (commonly known as the ‘Administrative Procedures Act’ [probably should be “
Administrative Procedure Act”]) or any other provision of law.”
Study and Report on the Development of Home Health Payment Revisions in Order To Ensure Access to Care and Payment for Severity of Illness
Pub. L. 111–148, title III, § 3131(d), title X, § 10315(b), Mar. 23, 2010, 124 Stat. 429, 944, provided that:
“(1) In general.—The Secretary of Health and Human Services (in this section referred to as the ‘Secretary’) shall conduct a study on home health agency costs involved with providing ongoing access to care to low-income Medicare beneficiaries or beneficiaries in medically underserved areas, and in treating beneficiaries with varying levels of severity of illness. In conducting the study, the Secretary may analyze items such as the following:
“(A) Methods to potentially revise the home health prospective payment system under section 1895 of the Social Security Act (42 U.S.C. 1395fff) to account for costs related to patient severity of illness or to improving beneficiary access to care, such as—
“(i)
payment adjustments for services that may involve additional or fewer resources;
“(ii)
changes to reflect resources involved with providing
home health services to low-income
Medicare beneficiaries or
Medicare beneficiaries residing in medically underserved areas;
“(iii)
ways outlier payments might be revised to reflect costs of treating Medicare beneficiaries with high levels of severity of illness; and
“(B)
Operational issues involved with potential implementation of potential revisions to the home health payment system, including impacts for both home health agencies and administrative and systems issues for the Centers for Medicare & Medicaid Services, and any possible payment vulnerabilities associated with implementing potential revisions.
“(C)
Whether additional research might be needed.
“(2) Considerations.—In conducting the study under paragraph (1), the Secretary may consider whether patient severity of illness and access to care could be measured by factors, such as—
“(A)
population density and relative patient access to care;
“(B)
variations in service costs for providing care to individuals who are dually eligible under the Medicare and Medicaid programs;
“(C)
the presence of severe or chronic diseases, which might be measured by multiple, discontinuous home health episodes;
“(3) Report.—
Not later than
March 1, 2014, the
Secretary shall submit to
Congress a report on the study conducted under paragraph (1), together with recommendations for such legislation and administrative action as the
Secretary determines
appropriate.
“(4) Consultations.—
In conducting the study under paragraph (1), the
Secretary shall consult with
appropriate stakeholders, such as groups representing home health agencies and groups representing
Medicare beneficiaries.
“(5) Medicare demonstration project based on the results of the study.—
“(A) In general.—
Subject to subparagraph (D), taking into account the results of the study conducted under paragraph (1), the
Secretary may, as determined
appropriate, provide for a demonstration project to test whether making payment adjustments for
home health services under the
Medicare program would substantially improve access to care for patients with high severity levels of illness or for low-income or underserved
Medicare beneficiaries.
“(B) Waiving budget neutrality.—
The
Secretary shall not reduce the standard prospective payment amount (or amounts) under section 1895 of the
Social Security Act (
42 U.S.C. 1395fff) applicable to
home health services furnished during a period to offset any increase in payments during such period resulting from the application of the payment adjustments under subparagraph (A).
“(C) No effect on subsequent periods.—A payment adjustment resulting from the application of subparagraph (A) for a period—
“(ii)
shall not be taken into account in calculating the payment amounts applicable for such services after such period.
“(D) Duration.—
If the
Secretary determines it
appropriate to conduct the demonstration project under this subsection, the
Secretary shall conduct the project for a four year period beginning not later than
January 1, 2015.
“(E) Funding.—
The
Secretary shall provide for the transfer 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 established under section 1841 of such Act (
42 U.S.C. 1395t), in such proportion as the
Secretary determines
appropriate, of $500,000,000 for the period of fiscal years 2015 through 2018. Such funds shall be made available for the study described in paragraph (1) and the design, implementation and evaluation of the demonstration described in this paragraph. Amounts available under this subparagraph shall be available until expended.
“(F) Evaluation and report.—If the Secretary determines it appropriate to conduct the demonstration project under this subsection, the Secretary shall—
“(i)
provide for an evaluation of the project; and
“(ii)
submit to
Congress, by a date specified by the
Secretary, a report on the project.
“(G) Administration.—
Chapter 35 of title 44,
United States Code, shall not apply with respect to this subsection.”
Temporary Increase for Home Health Services Furnished in a Rural Area
Pub. L. 108–173, title IV, § 421, Dec. 8, 2003, 117 Stat. 2283, as amended by Pub. L. 109–171, title V, § 5201(b), Feb. 8, 2006, 120 Stat. 46; Pub. L. 111–148, title III, § 3131(c), Mar. 23, 2010, 124 Stat. 428; Pub. L. 114–10, title II, § 210, Apr. 16, 2015, 129 Stat. 151; Pub. L. 115–123, div. E, title II, § 50208(a)(1), Feb. 9, 2018, 132 Stat. 188; Pub. L. 117–328, div. FF, title IV, § 4137, Dec. 29, 2022, 136 Stat. 5925, provided that:
“(a) In General.—
With respect to episodes and visits ending on or after
April 1, 2004, and before
April 1, 2005, episodes and visits beginning on or after
January 1, 2006, and before
January 1, 2007, and episodes and visits ending on or after
April 1, 2010, and before
January 1, 2019, in the case of
home health services furnished in a rural area (as defined in section 1886(d)(2)(D) of the
Social Security Act (
42 U.S.C. 1395ww(d)(2)(D))), the
Secretary [of Health and Human Services] shall increase the payment amount otherwise made under section 1895 of such Act (
42 U.S.C. 1395fff) for such services by 5 percent (or, in the case of episodes and visits ending on or after
April 1, 2010, and before
January 1, 2019, 3 percent).
“(b) Subsequent Temporary Increase.—
“(1) In general.—The Secretary shall increase the payment amount otherwise made under such section 1895 for home health services furnished in a county (or equivalent area) in a rural area (as defined in such section 1886(d)(2)(D)) that, as determined by the Secretary—
“(A) is in the highest quartile of all counties (or equivalent areas) based on the number of Medicare home health episodes furnished per 100 individuals who are entitled to, or enrolled for, benefits under part A of title XVIII of the Social Security Act [42 U.S.C. 1395c et seq.] or enrolled for benefits under part B of such title [42 U.S.C. 1395j et seq.] (but not enrolled in a plan under part C of such title [42 U.S.C. 1395w–21 et seq.])—
“(i)
in the case of episodes and visits ending during 2019, by 1.5 percent; and
“(ii)
in the case of episodes and visits ending during 2020, by 0.5 percent;
“(B) has a population density of 6 individuals or fewer per square mile of land area and is not described in subparagraph (A)—
“(i)
in the case of episodes and visits ending during 2019, by 4 percent;
“(ii)
in the case of episodes and visits ending during 2020, by 3 percent;
“(iii)
in the case of episodes and visits ending during 2021, by 2 percent;
“(iv)
in the case of episodes and visits ending during 2022, by 1 percent; and
“(v)
in the case of episodes and visits ending during 2023, by 1 percent; and
“(C) is not described in either subparagraph (A) or (B)—
“(i)
in the case of episodes and visits ending during 2019, by 3 percent;
“(ii)
in the case of episodes and visits ending during 2020, by 2 percent; and
“(iii)
in the case of episodes and visits ending during 2021, by 1 percent.
“(2) Rules for determinations.—
“(A) No switching.—
For purposes of this subsection, the determination by the
Secretary as to which subparagraph of paragraph (1) applies to a county (or equivalent area) shall be made a single time and shall apply for the duration of the period to which this subsection applies.
“(B) Utilization.—In determining which counties (or equivalent areas) are in the highest quartile under paragraph (1)(A), the following rules shall apply:
“(ii)
The
Secretary shall exclude data from the territories (and the territories shall not be described in such paragraph).
“(iii)
The
Secretary may exclude data from counties (or equivalent areas) in rural areas with a low volume of home health episodes (and if data is so excluded with respect to a county (or equivalent area), such county (or equivalent area) shall not be described in such paragraph).
“(C) Population density.—
In determining population density under paragraph (1)(B), the
Secretary shall use data from the 2010 decennial Census.
“(c) Waiving Budget Neutrality.—
The
Secretary shall not reduce the standard prospective payment amount (or amounts) under section 1895 of the
Social Security Act (
42 U.S.C. 1395fff) applicable to
home health services furnished during a period to offset the increase in payments resulting from the application of subsection (a) or (b).
“(d) No Effect on Subsequent Periods.—The payment increase provided under subsection (a) or (b) for a period under such subsection—
“(1)
shall not apply to episodes and visits ending after such period; and
“(2)
shall not be taken into account in calculating the payment amounts applicable for episodes and visits occurring after such period.”
Demonstration Project for Medical Adult Day-Care Services
Pub. L. 108–173, title VII, § 703, Dec. 8, 2003, 117 Stat. 2336, provided that:
“(a) Establishment.—
Subject to the succeeding provisions of this section, the
Secretary [of Health and Human Services] shall establish a demonstration project (in this section referred to as the ‘demonstration project’) under which the
Secretary shall, as part of a plan of an episode of care for
home health services established for a
medicare beneficiary, permit a
home health agency, directly or under arrangements with a medical adult day-care facility, to provide medical adult day-care services as a substitute for a portion of
home health services that would otherwise be provided in the beneficiary’s home.
“(b) Payment.—
“(1) In general.—
Subject to paragraph (2), the amount of payment for an episode of care for
home health services, a portion of which consists of substitute medical adult day-care services, under the demonstration project shall be made at a rate equal to 95 percent of the amount that would otherwise apply for such
home health services under section 1895 of the
Social Security Act (
42 U.S.C. 1395fff). In no case may a
home health agency, or a medical adult day-care facility under arrangements with a
home health agency, separately charge a beneficiary for medical adult day-care services furnished under the plan of care.
“(2) Adjustment in case of overutilization of substitute adult day-care services to ensure budget neutrality.—
The
Secretary shall monitor the expenditures under the demonstration project and under title XVIII of the
Social Security Act [
42 U.S.C. 1395 et seq.] for
home health services. If the
Secretary estimates that the total expenditures under the demonstration project and under such title XVIII for
home health services for a period determined by the
Secretary exceed expenditures that would have been made under such title XVIII for
home health services for such period if the demonstration project had not been conducted, the
Secretary shall adjust the rate of payment to medical adult day-care facilities under paragraph (1) in order to eliminate such excess.
“(c) Demonstration Project Sites.—
The demonstration project established under this section shall be conducted in not more than 5 sites in
States selected by the
Secretary that license or certify providers of services that furnish medical adult day-care services.
“(d) Duration.—
The
Secretary shall conduct the demonstration project for a period of 3 years.
“(e) Voluntary Participation.—
Participation of medicare beneficiaries in the demonstration project shall be voluntary. The total number of such beneficiaries that may participate in the project at any given time may not exceed 15,000.
“(f) Preference in Selecting Agencies.—
In selecting home health agencies to participate under the demonstration project, the
Secretary shall give preference to those agencies that are currently licensed or certified through common ownership and control to furnish medical adult day-care services.
“(g) Waiver Authority.—
The
Secretary may waive such requirements of title XVIII of the
Social Security Act [
42 U.S.C. 1395 et seq.] as may be necessary for the purposes of carrying out the demonstration project, other than waiving the requirement that an individual be homebound in order to be eligible for benefits for
home health services.
“(h) Evaluation and Report.—The Secretary shall conduct an evaluation of the clinical and cost-effectiveness of the demonstration project. Not later than 6 months after the completion of the project, the Secretary shall submit to Congress a report on the evaluation, and shall include in the report the following:
“(1)
An analysis of the patient outcomes and costs of furnishing care to the
medicare beneficiaries participating in the project as compared to such outcomes and costs to beneficiaries receiving only
home health services for the same health conditions.
“(2)
Such recommendations regarding the extension, expansion, or termination of the project as the
Secretary determines
appropriate.
“(i) Definitions.—In this section:
“(2) Medical adult day-care facility.—The term ‘medical adult day-care facility’ means a facility that—
“(A)
has been licensed or certified by a
State to furnish medical adult day-care services in the
State for a continuous 2-year period;
“(B)
is engaged in providing skilled nursing services and other therapeutic services directly or under arrangement with a
home health agency;
“(C)
is licensed and certified by the
State in which it operates or meets such standards established by the
Secretary to assure quality of care and such other requirements as the
Secretary finds necessary in the interest of the health and safety of individuals who are furnished services in the facility; and
“(D)
provides medical adult day-care services.
“(3) Medical adult day-care services.—The term ‘medical adult day-care services’ means—
“(A)
home health service items and services described in paragraphs (1) through (7) of section 1861(m) [probably means section 1861(m) of the
Social Security Act,
42 U.S.C. 1395x(m)] furnished in a medical adult day-care facility;
“(B) a program of supervised activities furnished in a group setting in the facility that—
“(ii)
is designed to promote physical and mental health of the individuals; and
“(C)
such other services as the
Secretary may specify.
“(4) Medicare beneficiary.—
The term ‘
medicare beneficiary’ means an individual entitled to benefits under part A of this title [probably means part A of title XVIII of the
Social Security Act,
42 U.S.C. 1395c et seq.], enrolled under part B of this title [probably means part B of title XVIII of the
Social Security Act,
42 U.S.C. 1395j et seq.], or both.”
Temporary Suspension of Oasis Requirement for Collection of Data on Non-Medicare and Non-Medicaid Patients
Pub. L. 108–173, title VII, § 704, Dec. 8, 2003, 117 Stat. 2338, provided that:
“(a) In General.—
During the period described in subsection (b), the
Secretary [of Health and Human Services] may not require, under section 4602(e) of the
Balanced Budget Act of 1997 (
Public Law 105–33;
111 Stat. 467) [set out as a note under this section] or otherwise under OASIS, a
home health agency to gather or submit information that relates to an individual who is not eligible for benefits under either title XVIII or title XIX of the
Social Security Act [
42 U.S.C. 1395 et seq., 1396 et seq.] (such information in this section referred to as ‘non-
medicare/medicaid OASIS information’).
“(b) Period of Suspension.—The period described in this subsection—
“(1)
begins on the date of the enactment of this Act [Dec. 8, 2003]; and
“(2)
ends on the last day of the second month beginning after the date as of which the
Secretary has published final
regulations regarding the collection and use by the Centers for
Medicare & Medicaid Services of non-
medicare/medicaid OASIS information following the submission of the report required under subsection (c).
“(c) Report.—
“(1) Study.—The Secretary shall conduct a study on how non-medicare/medicaid OASIS information is and can be used by large home health agencies. Such study shall examine—
“(A)
whether there are unique benefits from the analysis of such information that cannot be derived from other information available to, or collected by, such agencies; and
“(B)
the value of collecting such information by small home health agencies compared to the administrative burden related to such collection.
In conducting the study the
Secretary shall obtain recommendations from quality assessment experts in the use of such information and the necessity of small, as well as large, home health agencies collecting such information.
“(2) Report.—
The
Secretary shall submit to
Congress a report on the study conducted under paragraph (1) by not later than 18 months after the date of the enactment of this Act [
Dec. 8, 2003].
“(d) Construction.—
Nothing in this section shall be construed as preventing home health agencies from collecting non-medicare/medicaid OASIS information for their own use.”
MedPAC Study on Medicare Margins of Home Health Agencies
Pub. L. 108–173, title VII, § 705, Dec. 8, 2003, 117 Stat. 2339, provided that:
“(a) Study.—
The
Medicare Payment Advisory Commission shall conduct a study of payment margins of home health agencies under the home health prospective payment system under section 1895 of the
Social Security Act (
42 U.S.C. 1395fff). Such study shall examine whether systematic differences in payment margins are related to differences in case mix (as measured by home health resource groups (HHRGs)) among such agencies. The study shall use the partial or full-year cost reports filed by home health agencies.
“(b) Report.—
Not later than 2 years after the date of the enactment of this Act [Dec. 8, 2003], the Commission shall submit to Congress a report on the study under subsection (a).”
Special Rule for Payment for Fiscal Year 2001 Based on Adjusted Prospective Payment Amounts
Pub. L. 106–554, § 1(a)(6) [title V, § 502(b)], Dec. 21, 2000, 114 Stat. 2763, 2763A–530, provided that:
“(1) In general.—Notwithstanding the amendments made by subsection (a) [amending section 1395x of this title], for purposes of making payments under section 1895(b) of the Social Security Act (42 U.S.C. 1395fff(b)) for home health services furnished during fiscal year 2001, the Secretary of Health and Human Services shall—
“(A)
with respect to episodes and visits ending on or after
October 1, 2000, and before
April 1, 2001, use the final standardized and budget neutral prospective payment amounts for 60-day episodes and standardized average per visit amounts for fiscal year 2001 as published by the
Secretary in the Federal Register on
July 3, 2000 (
65 Fed. Reg. 41128–41214); and
“(B)
with respect to episodes and visits ending on or after April 1, 2001, and before October 1, 2001, use such amounts increased by 2.2 percent.
“(2) No effect on other payments or determinations.—
The
Secretary shall not take the provisions of paragraph (1) into account for purposes of payments, determinations, or budget neutrality adjustments under section 1895 of the
Social Security Act.”
Temporary Two-Month Periodic Interim Payment
Pub. L. 106–554, § 1(a)(6) [title V, § 503], Dec. 21, 2000, 114 Stat. 2763, 2763A–530, provided that:
“(a) In General.—
Notwithstanding the amendments made by section 4603(b) of BBA [
Pub. L. 105–33, amending
section 1395g of this title] (
42 U.S.C. 1395fff note), in the case of a
home health agency that was receiving periodic interim payments under section 1815(e)(2) of the
Social Security Act (
42 U.S.C. 1395g(e)(2)) as of
September 30, 2000, and that is not described in subsection (b), the
Secretary of Health and Human Services shall, as soon as practicable, make a single periodic interim payment to such agency in an amount equal to four times the last full fortnightly periodic interim payment made to such agency under the payment system in effect prior to the implementation of the prospective payment system under section 1895(b) of such Act (
42 U.S.C. 1395fff(b)). Such amount of such periodic interim payment shall be included in the tentative settlement of the last cost report for the
home health agency under the payment system in effect prior to the implementation of such prospective payment system, regardless of the ending date of such cost report.
“(b) Exceptions.—The Secretary shall not make an additional periodic interim payment under subsection (a) in the case of a home health agency (determined as of the day that such payment would otherwise be made) that—
“(1)
notifies the
Secretary that such agency does not want to receive such payment;
“(2)
is not receiving payments pursuant to
section 405.371 of title 42, Code of Federal Regulations;
“(4)
no longer has a provider agreement under section 1866 of such Act (
42 U.S.C. 1395cc);
“(5)
is no longer in business; or
“(6)
is subject to a court order providing for the withholding of
medicare payments under title XVIII of such Act [
42 U.S.C. 1395 et seq.].”
Clarification of Application of Temporary Payment Increases for 2001
Pub. L. 106–554, § 1(a)(6) [title V, § 547(c)], Dec. 21, 2000, 114 Stat. 2763, 2763A–553, provided that:
“(1) Transitional allowance for full marketbasket [sic] increase.—
The payment increase provided under
section 502(b)(1)(B) [set out as a note above] shall not apply to episodes and visits ending after fiscal year 2001 and shall not be taken into account in calculating the payment amounts applicable for subsequent episodes and visits.
“(2) Temporary increase for rural home health services.—
The payment increase provided under section 508(a) [set out as a note above] for the period beginning on April 1, 2001, and ending on September 30, 2002, shall not apply to episodes and visits ending after such period, and shall not be taken into account in calculating the payment amounts applicable for episodes and visits occurring after such period.”
Adjustment To Reflect Administrative Costs Not Included in the Interim Payment System; GAO Report on Costs of Compliance With Oasis Data Collection Requirements
Pub. L. 106–113, div. B, § 1000(a)(6) [title III, § 301], Nov. 29, 1999, 113 Stat. 1536, 1501A–358, provided that:
“(a) Adjustment To Reflect Administrative Costs
“(1) In general.—
In the case of a
home health agency that furnishes
home health services to a
medicare beneficiary, for each such beneficiary to whom the agency furnished such services during the agency’s cost reporting period beginning in fiscal year 2000, the
Secretary of Health and Human Services shall pay the agency, in addition to any amount of payment made under section 1861(v)(1)(L) of the
Social Security Act (
42 U.S.C. 1395x(v)(1)(L)) for the beneficiary and only for such cost reporting period, an aggregate amount of $10 to defray costs incurred by the agency attributable to data collection and reporting requirements under the Outcome and Assessment Information Set (OASIS) required by reason of section 4602(e) of BBA [the
Balanced Budget Act of 1997,
Pub. L. 105–33] (
42 U.S.C. 1395fff note).
“(2) Payment schedule
“(A) Midyear payment.—
Not later than
April 1, 2000, the
Secretary shall pay to a
home health agency an amount that the
Secretary estimates to be 50 percent of the aggregate amount payable to the agency by reason of this subsection.
“(B) Upon settled cost report.—
The
Secretary shall pay the balance of amounts payable to an agency under this subsection on the date that the cost report submitted by the agency for the cost reporting period beginning in fiscal year 2000 is settled.
“(3) Payment from trust funds.—
Payments under this subsection shall be made, in
appropriate part as specified by the
Secretary, from the Federal
Hospital Insurance Trust Fund and from the Federal Supplementary Medical Insurance Trust Fund.
“(4) Definitions.—In this subsection:
“(b) GAO Report on Costs of Compliance With OASIS Data Collection Requirements.—
“(1) Report to congress.—
“(A) In general.—
Not later than 180 days after the date of the enactment of this Act [
Nov. 29, 1999], the Comptroller General of the
United States shall submit to
Congress a report on the matters described in subparagraph (B) with respect to the data collection requirement of patients of such agencies under the Outcome and Assessment Information Set (OASIS) standard as part of the comprehensive assessment of patients.
“(B) Matters studied.—For purposes of subparagraph (A), the matters described in this subparagraph include the following:
“(i)
An assessment of the costs incurred by medicare home health agencies in complying with such data collection requirement.
“(ii)
An analysis of the effect of such data collection requirement on the privacy interests of patients from whom data is collected.
“(C) Audit.—
The Comptroller General shall conduct an independent audit of the costs described in subparagraph (B)(i). Not later than 180 days after receipt of the report under subparagraph (A), the Comptroller General shall submit to
Congress a report describing the Comptroller General’s findings with respect to such audit, and shall include comments on the report submitted to
Congress by the
Secretary of Health and Human Services under subparagraph (A).
“(2) Definitions.—In this subsection:
“(A) Comprehensive assessment of patients.—
The term ‘comprehensive assessment of patients’ means the rule published by the Health Care Financing
Administration that requires, as a condition of participation in the
medicare program, a
home health agency to provide a patient-specific comprehensive assessment that accurately reflects the patient’s current status and that incorporates the Outcome and Assessment Information Set (OASIS).
“(B) Outcome and assessment information set.—
The term ‘Outcome and Assessment Information Set’ means the standard provided under the rule relating to data items that must be used in conducting a comprehensive assessment of patients.”
Report to Congress on Need for Reductions
Pub. L. 106–113, div. B, § 1000(a)(6) [title III, § 302(c)], Nov. 29, 1999, 113 Stat. 1536, 1501A–360, as amended by Pub. L. 106–554, § 1(a)(6) [title V, § 501(b)], Dec. 21, 2000, 114 Stat. 2763, 2763A–529, provided that:
“Not later than
April 1, 2002, the Comptroller General of the
United States shall submit to
Congress a report analyzing the need for the 15 percent reduction under subsection (b)(3)(A)(ii) of such section [
42 U.S.C. 1395fff(b)(3)(A)(ii)], or for any reduction, in the computation of the base payment amounts under the prospective payment system for
home health services established under such section.”
Study and Report to Congress Regarding Exemption of Rural Agencies and Populations From Inclusion in Home Health Prospective Payment System
Pub. L. 106–113, div. B, § 1000(a)(6) [title III, § 307], Nov. 29, 1999, 113 Stat. 1536, 1501A–362, provided that:
“(a) Study.—
The
Medicare Payment Advisory Commission (referred to in this section as ‘MedPAC’) shall conduct a study to determine the feasibility and advisability of exempting
home health services provided by a
home health agency (or by others under arrangements with such agency) located in a rural area, or to an individual residing in a rural area, from payment under the prospective payment system for such services established by the
Secretary of Health and Human Services in accordance with section 1895 of the
Social Security Act (
42 U.S.C. 1395fff).
“(b) Report.—
Not later than 2 years after the date of the enactment of this Act [
Nov. 29, 1999], MedPAC shall submit a report to
Congress on the study conducted under subsection (a), together with any recommendations for legislation that MedPAC determines to be
appropriate as a result of such study.”
Case Mix System Development
Pub. L. 105–33, title IV, § 4602(d), Aug. 5, 1997, 111 Stat. 467, provided that:
“The
Secretary of Health and Human Services shall expand research on a prospective payment system for home health agencies under the
medicare program that ties prospective payments to a unit of service, including an intensive effort to develop a reliable case mix adjuster that explains a significant amount of the variances in costs.”
Case Mix System; Submission of Data
Pub. L. 105–33, title IV, § 4602(e), Aug. 5, 1997, 111 Stat. 467, provided that:
“Effective for cost reporting periods beginning on or after
October 1, 1997, the
Secretary of Health and Human Services may require all home health agencies to submit additional information that the
Secretary considers necessary for the development of a reliable case mix system.”
Prospective Payment System Contingency
Pub. L. 105–33, title IV, § 4603(e), Aug. 5, 1997, 111 Stat. 471, as amended by Pub. L. 105–277, div. J, title V, § 5101(c)(3), Oct. 21, 1998, 112 Stat. 2681–914, provided that if the Secretary of Health and Human Services did not establish and implement the prospective payment system for home health services described in subsec. (b) of this section for portions of cost reporting periods described in section 4603(d) of Pub. L. 105–33 (set out as a note above), for such portions the Secretary was to provide for a reduction by 15 percent in the cost limits and per beneficiary limits described in section 1395x(v)(1)(L) of this title, as those limits would otherwise have been in effect on Sept. 30, 2000, prior to repeal by Pub. L. 106–113, div. B, § 1000(a)(6) [title III, § 302(a)], Nov. 29, 1999, 113 Stat. 1536, 1501A–359.
Reports to Congress Regarding Home Health Cost Containment
Pub. L. 105–33, title IV, § 4616, Aug. 5, 1997, 111 Stat. 475, provided that:
“(a) Estimate.—
Not later than
October 1, 1997, the
Secretary of Health and Human Services shall submit to the Committees on Commerce and Ways and Means of the
House of Representatives and the Committee on Finance of the
Senate a report that includes an estimate of the outlays that will be made under parts A and B of title XVIII of the
Social Security Act [
42 U.S.C. 1395c et seq., 1395j et seq.] for the provision of
home health services during each of fiscal years 1998 through 2002.
“(b) Annual Report.—
Not later than the end of each of years 1999 through 2002, the
Secretary shall submit to such Committees a report that compares the actual outlays under such parts for such services during the fiscal year ending in the year, to the outlays estimated under subsection (a) for such fiscal year. If the
Secretary finds that such actual outlays were greater than such estimated outlays for the fiscal year, the
Secretary shall include in the report recommendations regarding beneficiary copayments for
home health services provided under the
medicare program or such other methods as will reduce the growth in outlays for
home health services under the
medicare program.”
