[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 9125 Introduced in House (IH)]
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118th CONGRESS
2d Session
H. R. 9125
To amend title XVIII of the Social Security Act to improve the accuracy
and predictability of Medicare payments to long-term care hospitals.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 24, 2024
Mrs. Miller of West Virginia (for herself, Ms. Van Duyne, Mr. Smucker,
Mr. Smith of Nebraska, and Mr. Joyce of Pennsylvania) introduced the
following bill; which was referred to the Committee on Ways and Means
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to improve the accuracy
and predictability of Medicare payments to long-term care hospitals.
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 ``Patient Access to LTCH Care Act''.
SEC. 2. ENSURING ADEQUACY OF PAYMENTS FOR HIGH-ACUITY LONG-TERM CARE
HOSPITAL PATIENTS.
(a) In General.--Section 1886(m)(7) of the Social Security Act (42
U.S.C. 1395ww(m)(7)) is amended--
(1) in subparagraph (B)--
(A) by striking ``Notwithstanding subparagraph
(A)'' and inserting the following:
``(i) In general.--Notwithstanding
subparagraph (A)''; and
(B) by adding at the end the following new clause:
``(ii) Limitation on increase of fixed loss
amount.--Notwithstanding clause (i)--
``(I) in the case that application
of such clause would result in a fixed
loss amount established for fiscal year
2025 or 2026 that is greater than
$50,000, the Secretary shall set such
fixed loss amount for such fiscal year
at $50,000; and
``(II) in the case that application
of such clause would result in a fixed
loss amount established for fiscal year
2027 or a subsequent fiscal year that
is greater than 110 percent of the
fixed loss amount established for the
preceding fiscal year, the Secretary
shall set such fixed loss amount for
such fiscal year at 110 percent of the
fixed loss amount established for the
preceding fiscal year.''; and
(2) in subparagraph (C), by striking ``reduction'' and
inserting ``change''.
(b) Payment Adjustment for Complex Long-Term Care Hospital
Patients.--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:
``(8) Payment adjustment for patients with complications or
comorbidities or major complications or comorbidities.--
``(A) In general.--For discharges occurring on or
after October 1, 2025, or such earlier date as the
Secretary may specify, the Secretary shall increase
payment rates under the system described in paragraph
(1) in accordance with subparagraph (B) to fully
account for the higher costs associated with treating
the highest complexity individuals.
``(B) Increase.--In calculating payment rates under
the system described in paragraph (1) for a discharge
of an individual occurring on or after October 1, 2025
(or such earlier date as the Secretary may specify),
the Secretary shall--
``(i) in the case such individual had more
than 5 major complications or comorbidities and
fewer than 6 complications or comorbidities
that were not major or had between 3 and 5
major complications and comorbidities and 5 or
more complications and comorbidities that were
not major (as demonstrated by claims data on
the claim form submitted by the long-term care
hospital), increase the payment weight for the
applicable diagnosis-related group by 5
percent; and
``(ii) in the case such individual had more
than 5 major complications or comorbidities and
more than 5 complications or comorbidities that
were not major (as so demonstrated), increase
the payment weight for the applicable
diagnosis-related group by 10 percent.
``(C) Assumptions and adjustments.--
``(i) In general.--The Secretary shall
annually determine the impact of ICD-10 coding
changes on aggregate spending as a result of
the application of the payment increases under
subparagraph (A) with respect to fiscal years
2026 through 2030.
``(ii) Permanent adjustments.--The
Secretary shall, at a time and in a manner
determined appropriate by the Secretary,
through notice and comment rulemaking, provide
for one or more permanent increases or
decreases to the standard prospective payment
amount (or amounts) for fiscal years referenced
in clause (i), on a prospective basis, to
offset for increases or decreases in aggregate
expenditures associated with coding changes
attributable to the application of the payment
increases under subparagraph (A).
``(iii) Temporary adjustments for
retrospective behavior.--The Secretary shall,
at a time and in a manner determined
appropriate by the Secretary, through notice
and comment rulemaking, provide for one or more
temporary increases or decreases to the
standard prospective payment amount (or
amounts) for fiscal years referenced in clause
(i). Such a temporary increase or decrease
shall apply only with respect to the fiscal
year for which such temporary increase or
decrease is made, and the Secretary shall not
take into account such a temporary increase or
decrease in computing such amount under this
subsection for a subsequent fiscal year.
``(D) Nonapplication of budget neutrality.--The
additional payments resulting from the application of
this paragraph shall not be implemented in a budget
neutral manner.''.
SEC. 3. SAFEGUARDING SERVICES FOR LONG-TERM CARE HOSPITAL PATIENTS WITH
CERTAIN COMPLEX CONDITIONS.
Section 1886(m)(6) of the Social Security Act (42 U.S.C.
1395ww(m)(6)) is amended--
(1) in subparagraph (A)--
(A) in clause (i), by striking ``and (G)'' and
inserting ``(G), and (H)'';
(B) in clause (iii)(I), by inserting ``or, with
respect to discharges from a long-term care hospital
occurring on or after October 1, 2023, by a discharge
from a stay in a critical access hospital,'' after
``from a subsection (d) hospital''; and
(C) in clause (iv)(I), by inserting ``for
discharges from a long-term care hospital occurring
before October 1, 2023,'' before ``the stay in the
long-term care hospital''.
(2) by adding at the end the following new subparagraph:
``(H) Additional exception for patients with
certain complex conditions.--
``(i) In general.--For a discharge in a
cost reporting period beginning on or after
October 1, 2023, subparagraph (A)(i) shall not
apply (and payment shall be made to a long-term
care hospital without regard to this paragraph)
if such discharge--
``(I) meets either of the criteria
described in clause (ii); and
``(II) does not have a principal
diagnosis relating to a psychiatric
diagnosis or to rehabilitation.
``(ii) Criteria described.--For purposes of
clause (i), the criteria described in this
clause are, with respect to a discharge of an
individual from a long-term care hospital, the
following:
``(I) The stay in the long-term
care hospital ending with such
discharge was immediately preceded by a
discharge from a stay in a subsection
(d) hospital or a critical access
hospital and--
``(aa) such individual was
treated at the long-term care
hospital for a severe wound (as
defined in clause (iii));
``(bb) such discharge from
such long-term care hospital is
assigned to Medicare-Severity-
Long-Term-Care-Diagnosis-
Related-Group (MS-LTC-DRG) 189
relating to pulmonary edema and
respiratory failure (or any
successor MS-LTC-DRG);
``(cc) such discharge from
such long-term care hospital is
assigned to MS-LTC-DRG 871
relating to septicemia or
severe sepsis without
mechanical ventilation greater
than 96 hours with major
complications or comorbidities
(or any successor MS-LTC-DRG);
or
``(dd) such individual was
treated at the long-term care
hospital for COVID-19.
``(II) The discharge from such
long-term care hospital is assigned to
a MS-LTC-DRG with a relative weight
that is equal to or greater than the
specified amount (as defined in clause
(iii)) for the fiscal year in which
such discharge occurred.
``(iii) Definitions.--In this subparagraph:
``(I) Severe wound.--The term
`severe wound' means a stage 3 wound,
stage 4 wound, unstageable wound, non-
healing surgical wound, infected wound,
fistula, osteomyelitis, or a wound with
morbid obesity, as identified by
applicable codes on the claim from the
long-term care hospital.
``(II) Specified amount.--The term
`specified amount' means, with respect
to fiscal year, an amount equal to the
80th percentile of the relative weights
for MS-LTC-DRGs that were assigned to
primary diagnoses for all discharges
occurring in the preceding fiscal year.
``(III) Wound.--The term `wound'
means as an injury involving division
of tissue or rupture or the integument
or mucous membrane with exposure to the
external environment.''.
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