Medicare Home Health Fraud Reduction Act

“(7) Episode utilization rate

“(A) Payment limitation—For 2014 and each subsequent year, payment may not be made to a skilled home health agency under this section for an episode of care to the extent that such episode exceeds the applicable episode utilization limit established under subparagraph (B) for the agency for the year.

“(B) Applicable episode utilization limit

“(i) In general—For 2014 and each subsequent year, the Secretary shall establish an episode utilization limit for a skilled home health agency that is equal to the product of—

“(I) in the case of a skilled home health agency located in—

“(aa) a rural area, 3.3 episodes; and

“(bb) in an area not described in item (aa), 2.7 episodes; and

“(II) the total number of Medicare beneficiaries for the skilled home health agency (as defined in clause (iii)).

“(ii) Episode defined—For purposes of this paragraph, the term episode has the meaning given such term for purposes of section 484.205 of title 42, Code of Federal Regulations (as in effect on October 1, 2011) and includes partial episodes for which a partial episode payment is made pursuant to such section to the extent such partial episode is a percentage of a full episode.

“(iii) Total number of medicare beneficiaries defined

“(I) In general—For purposes of clause (i)(II), the term total number of Medicare beneficiaries means, with respect to a skilled home health agency and year, the total number of unduplicated individuals who were furnished home health services under this title in the year by the agency.

“(II) Special rule—In calculating the total number of Medicare beneficiaries under subclause (I), in any case where an individual is furnished skilled home health care services from more than one agency, the number of such individuals being counted toward the applicable episode utilization limit for each such agency shall be proportionally credited in an amount equal to the percentage of the total number of episodes provided by the agency.”