H.R. 5273 — what changed
Helping Hospitals Improve Patient Care Act of 2016
From Introduced in House to Reported in House. 6 sections amended between Introduced in House and Reported in House.
Sec. 102 Establishing beneficiary equity in the Medicare hospital readmission program
Transitional adjustment for dual eligible population— Section 1886(q)(3) of the Social Security Act (42 U.S.C. 1395ww(q)(3)) is amended—
in subparagraph (A), by inserting “subject to subparagraph (D),” after “purposes of paragraph (1),”; and
by adding at the end the following new subparagraph:
“(D) Transitional adjustment for dual eligibles
“(i) In general—In determining a hospital’s adjustment factor under this paragraph for purposes of making payments for discharges occurring during and after fiscal year 2019, and before the application of clause (i) of subparagraph (E), the Secretary shall assign hospitals to groups (as defined by the Secretary under clause (ii)) and apply the applicable provisions of this subsection using a methodology in a manner that allows for separate comparison of hospitals within each such group, as determined by the Secretary.
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“(ii) Defining groups—For purposes of this subparagraph, the Secretary shall define groups of hospitals based on their overall proportion proportion, of the inpatients who are entitled to, or enrolled for, benefits under part A, who are full-benefit dual eligible individuals (as defined in section 1935(c)(6)). In defining groups, the Secretary shall consult the Medicare Payment Advisory Commission and may consider the analysis done by such Commission in preparing the portion of its report submitted to Congress in June 2013 relating to readmissions.
“(iii) Minimizing reporting burden on hospitals—In carrying out this subparagraph, the Secretary shall not impose any additional reporting requirements on hospitals.
“(iv) Budget neutral design methodology—The Secretary shall design the methodology to implement this subparagraph so that the estimated total amount of reductions in payments under this subsection equals the estimated total amount of reductions in payments that would otherwise occur under this subsection if this subparagraph did not apply.”
Subsequent adjustments based on IMPACT reports— Section 1886(q)(3) of the Social Security Act (42 U.S.C. 1395ww(q)(3)), as amended by subsection (a), is further amended by adding at the end the following new subparagraph:
“(E) Changes in risk adjustment
“(i) Consideration of recommendations in IMPACT reports—The Secretary may take into account the studies conducted and the recommendations made by the Secretary under section 2(d)(1) of the IMPACT Act of 2014 (Public Law 113–185; 42 U.S.C. 1395lll note) with respect to the application under this subsection of risk adjustment methodologies. Nothing in this clause shall be construed as precluding consideration of the use of groupings of hospitals.”
MedPAC study on readmissions program— The Medicare Payment Advisory Commission shall conduct a study to review overall hospital readmissions described in section 1886(q)(5)(E) of the Social Security Act (42 U.S.C. 1395ww(q)(5)(E)) and whether such readmissions are related to any changes in outpatient and emergency services furnished. The Commission shall submit to Congress a report on such study in its report to Congress in June 2017.
Addressing issue of certain patients— Subparagraph (E) of section 1886(q)(3) of the Social Security Act (42 U.S.C. 1395ww(q)(3)), as added by subsection (b), is further amended by adding at the end the following new clause:
“(ii) Consideration of exclusion of patient cases based on V or other appropriate codes—In promulgating regulations to carry out this subsection with respect to discharges occurring after fiscal year 2018, the Secretary may consider the use of V or other ICD-related codes for removal of a readmission. The Secretary may consider modifying measures under this subsection to incorporate V or other ICD-related codes at the same time as other changes are being made under this subparagraph.”
Removal of certain readmissions— Subparagraph (E) of section 1886(q)(3) of the Social Security Act (42 U.S.C. 1395ww(q)(3)), as added by subsection (b) and amended by subsection (d), is further amended by adding at the end the following new clause:
“(iii) Removal of certain readmissions—In promulgating regulations to carry out this subsection, with respect to discharges occurring after fiscal year 2018, the Secretary may consider removal as a readmission of an admission that is classified within one or more of the following: transplants, end-stage renal disease, burns, trauma, psychosis, or substance abuse. The Secretary may consider modifying measures under this subsection to remove readmissions at the same time as other changes are being made under this subparagraph.”
Sec. 104 Regulatory relief for LTCHs
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Technical change to the Medicare long-Term long-term care hospital moratorium exception—
In general— Section 114(d)(7) 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, section 1206(b)(2) of the Pathway for SGR Reform Act of 2013 (division B of Public Law 113–67), and section 112 of the Protecting Access to Medicare Act of 2014, is amended by striking “The moratorium under paragraph (1)(A)” and inserting “Any moratorium under paragraph (1)”.
Effective date— The amendment made by paragraph (1) shall take effect as if included in the enactment of section 112 of the Protecting Access to Medicare Act of 2014.
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Modification to Medicare long-Term long-term care hospital high cost outlier payments— Section 1886(m) of the Social Security Act (42 U.S.C. 1395ww(m)) is amended by adding at the end the following new paragraph:
“(7) Treatment of high cost outlier payments
“(A) Adjustment to the standard Federal payment rate for estimated high cost outlier payments—Under the system described in paragraph (1), for fiscal years beginning on or after October 1, 2017, the Secretary shall reduce the standard Federal payment rate as if the estimated aggregate amount of high cost outlier payments for standard Federal payment rate discharges for each such fiscal year would be equal to 8 percent of estimated aggregate payments for standard Federal payment rate discharges for each such fiscal year.
“(B) Limitation on high cost outlier payment amounts—Notwithstanding subparagraph (A), the Secretary shall set the fixed loss amount for high cost outlier payments such that the estimated aggregate amount of high cost outlier payments made for standard Federal payment rate discharges for fiscal years beginning on or after October 1, 2017, shall be equal to 99.6875 percent of 8 percent of estimated aggregate payments for standard Federal payment rate discharges for each such fiscal year.
“(C) Waiver of budget neutrality—Any reduction in payments resulting from the application of subparagraph (B) shall not be taken into account in applying any budget neutrality provision under such system.
“(D) No effect on site neutral high cost outlier payment rate—This paragraph shall not apply with respect to the computation of the applicable site neutral payment rate under paragraph (6).”
Sec. 105 Savings from IPPS MACRA pay-for through not applying documentation and coding adjustments
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Section 7(b)(1)(B)(iii) of the TMA, Abstinence Education, and QI Programs Extension Act of 2007 (Public Law 110–90), as amended by section 631(b) of the American Taxpayer Relief Act of 2012 (Public Law 122–240) and section 414(1)(B)(iii) of the Medicare Access and CHIP Reauthorization Act of 2015 (Public Law 114–10), is amended by striking “0.5 “an increase of 0.5 percentage points” points for discharges occurring during each of fiscal years 2018 through 2023” and inserting “0.4590 “an increase of 0.4590 percentage points”.points for discharges occurring during fiscal year 2018 and 0.5 percentage points for discharges occurring during each of fiscal years 2019 through 2023”.
Sec. 201 Continuing Medicare payment under HOPD prospective payment system for services furnished by mid-build off-campus outpatient departments of providers
In general— Section 1833(t)(21) of the Social Security Act (42 U.S.C. 1395l(t)(21)) is amended—
in subparagraph (B)—
in clause (i), by striking “clause (ii)” and inserting “the subsequent provisions of this subparagraph”; and
by adding at the end the following new clauses:
“(iii) Deemed treatment for 2017—For purposes of applying clause (ii) with respect to applicable items and services furnished during 2017, a department of a provider (as so defined) not described in such clause is deemed to be billing under this subsection with respect to covered OPD services furnished prior to November 2, 2015, if the Secretary received from the provider prior to December 2, 2015, an attestation (pursuant to section 413.65(b)(3) of title 42 of the Code of Federal Regulations) that such department was a department of a provider (as so defined).
“(iv) Alternative exception beginning with 2018—For purposes of paragraph (1)(B)(v) and this paragraph with respect to applicable items and services furnished during 2018 or a subsequent year, the term off-campus outpatient department of a provider also shall not include a department of a provider (as so defined) that is not described in clause (ii) if—
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“(I) the Secretary receives from the provider an attestation (pursuant to such section 413.65(b)(3)) before July 1, 2016, not later than December 31, 2016 (or, if later, 60 days after the date of the enactment of this clause), that such department met the requirements of a department of a provider specified in section 413.65 of title 42 of the Code of Federal Regulations;
“(II) the provider includes such department as part of the provider on its enrollment form in accordance with the enrollment process under section 1866(j); and
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“(III) before July 1, 2016, the department met the mid-build requirement of clause (v) and the Secretary receives receives, not later than 60 days after the date of the enactment of this clause, from the chief executive officer or chief operating officer of the provider a written certification that the department met such requirement.
“(v) Mid-build requirement described—The mid-build requirement of this clause is, with respect to a department of a provider, that before November 2, 2015, the provider had a binding written agreement with an outside unrelated party for the actual construction of such department.
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“(vi) “(vii) Audit—Not later than December 31, 2018, the Secretary shall audit the compliance with requirements of clause (iv) with respect to a each department of a provider for to which an attestation is submitted under such clause. clause applies. If the Secretary finds as a result of an audit under this clause that the applicable requirements were not met with respect to such department, the department shall not be excluded from the term off-campus outpatient department of a provider under the respective such clause.
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“(vii) “(viii) Implementation—For purposes of implementing clauses (iii) through (vii):
“(I) Notwithstanding any other provision of law, the Secretary may implement such clauses by program instruction or otherwise.
“(II) Subchapter I of chapter 35 of title 44, United States Code, shall not apply.
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“(III) For purposes of carrying out this subparagraph with respect to clauses (iii) and (iv) (and clause (vii) insofar as it relates to such clauses), clause (iv)), the Secretary shall provide for the transfer from the Supplementary Medical Insurance Trust Fund under section 1841, of $10,000,000 to the Centers for Medicare & Medicaid Services Program Management Account to remain available until December 31, 2018.”
in subparagraph (E), by adding at the end the following new clause:
“(iv) The determination of an audit under subparagraph (B)(vii).”
Effective date— The amendments made by this section shall be effective as if included in the enactment of section 603 of the Bipartisan Budget Act of 2015 (Public Law 114–74).
Sec. 301 Delay in authority to terminate contracts for Medicare Advantage plans failing to achieve minimum quality ratings
Findings— Consistent with the studies provided under the IMPACT Act of 2014 (Public Law 113–185), it is the intent of Congress—
to continue to study and request input on the effects of socioeconomic status and dual-eligible populations on the Medicare Advantage STARS rating system before reforming such system with the input of stakeholders; and
pending the results of such studies and input, to provide for a temporary delay in authority of the Centers for Medicare & Medicaid Services (CMS) to terminate Medicare Advantage plan contracts solely on the basis of performance of plans under the STARS rating system.
Delay in MA contract termination authority for plans failing To achieve minimum quality ratings— Section 1857(h) of the Social Security Act (42 U.S.C. 1395w–27(h)) is amended by adding at the end the following new paragraph:
changed “(3) Delay in contract termination authority for plans failing to achieve minimum quality rating—During the period beginning on the date of the enactment of this paragraph and through the end of plan year 2018, the Secretary may not terminate a contract under this section with respect to the offering of an MA plan by a Medicare Advantage organization solely because the MA plan has failed to achieve a minimum quality rating under the 5-star rating system under section 1853(o)(4).”
Sec. 303 Updating the Welcome to Medicare package
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In general— Not later than 12 months after the last day of the period for the request of information described in subsection (b), the Secretary of Health and Human Services shall, taking into consideration information collected pursuant to subsection (b), update the information included in the Welcome to Medicare package to include information, presented in a clear and simple manner, about options for receiving benefits under the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.), including through the original medicare fee-for-service program under parts A and B of such title (42 U.S.C. 1395c et seq., 42 U.S.C. 1395j et seq.), Medicare Advantage plans under part C of such title (42 U.S.C. 1395w–21 et seq.), and prescription drug plans under part D of such title (42 U.S.C. 1395w–101 et seq.). seq.)). The Secretary shall make subsequent updates to the information included in the Welcome to Medicare package as appropriate.
Request for information— Not later than six months after the date of the enactment of this Act, the Secretary of Health and Human Services shall request information, including recommendations, from stakeholders (including patient advocates, issuers, and employers) on information included in the Welcome to Medicare package, including pertinent data and information regarding enrollment and coverage for Medicare eligible individuals.