,,ii  #aacth ,,congress  #b;d ,session  
,h4 ,r4 #diid  ,,in ,,the ,,senate ,,of 
,,the ,,united ,,states  ,september #ag 
7legislative day1 ,september #af71      
#bjad,received  ,,an ,,act  ,to amend   
title ,,xviii of the ,social ,security  
,act to provide for standardized        
post-acute care assessment data for     
quality1 payment1 and discharge         
planning1 and for other purposes4  #a4  
,short title ,this ,act may be cited as 
the ,improving ,medicare ,post-,acute   
,care ,transformation ,act of #bjad or  
the ,,impact ,act of #bjad 4  #b4       
,standardization of post-acute care data
  7a7 ,in general ,title ,,xviii of the 
,social ,security ,act is amended by    
adding at the end the following new     
section3  #ahii;,b4 ,standardized       
,post-,acute ,care 7,,pac7 assessment   
data for quality1 payment1 and discharge
 planning  7a7 ,requirement for         
standardized assessment data  7#a7 ,in  
general ,the ,secretary shall--  7,a7   
require under the applicable reporting  

provisions post-acute care providers 7as
 defined in paragraph 7#b77;,a77 to     
report--  7i7 standardized patient      
assessment data in accordance with      
subsection 7b72  7ii7 data on quality   
measures under subsection 7c77#a72 and  
7iii7 data on resource use and other    
measures under subsection 7d77#a72  7,b7
 require data described in subparagraph 
7,a7 to be standardized and             
interoperable so as to allow for the    
exchange of such data among such        
post-acute care providers and other     
providers and the use by such providers 
of such data that has been so exchanged1
 including by using common standards and
 definitions1 in order to provide access
 to longitudinal information for such   
providers to facilitate coordinated care
 and improved ,medicare beneficiary     
outcomes2 and  7,c7 in accordance with  
subsections 7b77#a7 and 7c77#b71 modify 
,,pac assessment instruments 7as defined
 in paragraph 7#b77;,b77 applicable to  
post-acute care providers to--  7i7     

provide for the submission of           
standardized patient assessment data    
under this title with respect to such   
providers2 and  7ii7 enable comparison  
of such assessment data across all such 
providers to whom such data are         
applicable4  7#b7 ,definitions ,for     
purposes of this section3  7,a7         
,post-acute care 7,,pac7 provider ,the  
terms post-acute care provider and ,,pac
 provider mean--  7i7 a home health     
agency2  7ii7 a skilled nursing         
facility2  7iii7 an inpatient           
rehabilitation facility2 and  7iv7 a    
long-term care hospital 7other than a   
hospital classified under section       
#ahhf7;d77#a77;,b77iv77,,ii774  7,b7    
,,pac assessment instrument ,the term   
,,pac assessment instrument means--  7i7
 in the case of home health agencies1   
the instrument used for purposes of     
reporting and assessment with respect to
 the ,outcome and ,assessment           
,information ,set 7,,oasis71 as         
described in sections #dhd4ee and       

#dhd4bej of title #db1 the ,code of     
,federal ,regulations1 or any successor 
regulation1 or any other instrument used
 with respect to home health agencies   
for such purposes2  7ii7 in the case of 
skilled nursing facilities1 the         
resident's assessment under section     
#ahai7;b77#c72  7iii7 in the case of    
inpatient rehabilitation facilities1 any
 ,medicare beneficiary assessment       
instrument established by the ,secretary
 for purposes of section #ahhf7;j72 and 
7iv7 in the case of long-term care      
hospitals1 the ,medicare beneficiary    
assessment instrument used with respect 
to such hospitals for the collection of 
data elements necessary to calculate    
quality measures as described in the    
,august #ah1 #bjaa1 ,federal ,register  
7#gf ,fed4 ,reg4 #eaged-eagee71         
including for purposes of section       
#ahhf7m77#e77;,c71 or any other         
instrument used with respect to such    
hospitals for assessment purposes4  7,c7
 ,applicable reporting provision ,the   

term applicable reporting provision     
means--  7i7 for home health agencies1  
section #ahie7;b77#c77;,b77v72  7ii7 for
 skilled nursing facilities1 section    
#ahhh7;e77#f72  7iii7 for inpatient     
rehabilitation facilities1 section      
#ahhf7;j77#g72 and  7iv7 for long-term  
care hospitals1 section #ahhf7m77#e74   
7,d7 ,,pac payment system ,the term     
,,pac payment system means--  7i7 with  
respect to a home health agency1 the    
prospective payment system under section
 #ahie2  7ii7 with respect to a skilled 
nursing facility1 the prospective       
payment system under section #ahhh7;e72 
7iii7 with respect to an inpatient      
rehabilitation facility1 the prospective
 payment system under section #ahhf7;j72
 and  7iv7 with respect to a long-term  
care hospital1 the prospective payment  
system under section #ahhf7m74  7,e7    
,specified application date ,the term   
specified application date means the    
following3  7i7 ,quality measures ,in   
the case of quality measures under      

subsection 7c77#a7--  7,i7 with respect 
to the domain described in subsection   
7c77#a77;,a7 7relating to functional    
status1 cognitive function1 and changes 
in function and cognitive function7--   
7aa7 for ,,pac providers described in   
clauses 7ii7 and 7iii7 of paragraph     
7#b77;,a71 ,october #a1 #bjaf2  7bb7 for
 ,,pac providers described in clause    
7iv7 of such paragraph1 ,october #a1    
#bjah2 and  7cc7 for ,,pac providers    
described in clause 7i7 of such         
paragraph1 ,january #a1 #bjai2  7,,ii7  
with respect to the domain described in 
subsection 7c77#a77;,b7 7relating to    
skin integrity and changes in skin      
integrity7--  7aa7 for ,,pac providers  
described in clauses 7ii71 7iii71 and   
7iv7 of paragraph 7#b77;,a71 ,october   
#a1 #bjaf2 and  7bb7 for ,,pac providers
 described in clause 7i7 of such        
paragraph1 ,january #a1 #bjag2  7,,iii7 
with respect to the domain described in 
subsection 7c77#a77;,c7 7relating to    
medication reconciliation7--  7aa7 for  

,,pac providers described in clause 7i7 
of such paragraph1 ,january #a1 #bjag2  
and  7bb7 for ,,pac providers described 
in clauses 7ii71 7iii71 and 7iv7 of such
 paragraph1 ,october #a1 #bjah2  7,,iv7 
with respect to the domain described in 
subsection 7c77#a77;,d7 7relating to    
incidence of major falls7--  7aa7 for   
,,pac providers described in clauses    
7ii71 7iii71 and 7iv7 of paragraph      
7#b77;,a71 ,october #a1 #bjaf2 and  7bb7
 for ,,pac providers described in clause
 7i7 of such paragraph1 ,january #a1    
#bjai2 and  7,v7 with respect to the    
domain described in subsection          
7c77#a77;,e7 7relating to accurately    
communicating the existence of and      
providing for the transfer of health    
information and care preferences7--     
7aa7 for ,,pac providers described in   
clauses 7ii71 7iii71 and 7iv7 of        
paragraph 7#b77;,a71 ,october #a1 #bjah2
 and  7bb7 for ,,pac providers described
 in clause 7i7 of such paragraph1       
,january #a1 #bjai4  7ii7 ,resource use 

and other measures ,in the case of      
resource use and other measures under   
subsection 7d77#a7--  7,i7 for ,,pac    
providers described in clauses 7ii71    
7iii71 and 7iv7 of paragraph 7#b77;,a71 
,october #a1 #bjaf2 and  7,,ii7 for     
,,pac providers described in clause 7i7 
of such paragraph1 ,january #a1 #bjag4  
7,f7 ,medicare beneficiary ,the term    
,medicare beneficiary means an          
individual entitled to benefits under   
part ,a or1 as appropriate1 enrolled for
 benefits under part ,b4  7b7           
,standardized patient assessment data   
7#a7 ,requirement for reporting         
assessment data  7,a7 ,in general       
,beginning not later than ,october #a1  
#bjah1 for ,,pac providers described in 
clauses 7ii71 7iii71 and 7iv7 of        
subsection 7a77#b77;,a7 and ,january #a1
 #bjai1 for ,,pac providers described in
 clause 7i7 of such subsection1 the     
,secretary shall require ,,pac providers
 to submit to the ,secretary1 under the 
applicable reporting provisions and     

through the use of ,,pac assessment     
instruments1 the standardized patient   
assessment data described in            
subparagraph 7,b74 ,the ,secretary shall
 require such data be submitted with    
respect to admission and discharge of an
 individual 7and may be submitted more  
frequently as the ,secretary deems      
appropriate74  7,b7 ,standardized       
patient assessment data described ,for  
purposes of subparagraph 7,a71 the      
standardized patient assessment data    
described in this subparagraph is data  
required for at least the quality       
measures described in subsection 7c77#a7
 and that is with respect to the        
following categories3  7i7 ,functional  
status1 such as mobility and self care  
at admission to a ,,pac provider and    
before discharge from a ,,pac provider4 
7ii7 ,cognitive function1 such as       
ability to express ideas and to         
understand1 and mental status1 such as  
depression and dementia4  7iii7 ,special
 services1 treatments1 and              

interventions1 such as need for         
ventilator use1 dialysis1 chemotherapy1 
central line placement1 and total       
parenteral nutrition4  7iv7 ,medical    
conditions and co-morbidities1 such as  
diabetes1 congestive heart failure1 and 
pressure ulcers4  7v7 ,impairments1 such
 as incontinence and an impaired ability
 to hear1 see1 or swallow4  7vi7 ,other 
categories deemed necessary and         
appropriate by the ,secretary4  7#b7    
,alignment of claims data with          
standardized patient assessment data ,to
 the extent practicable1 not later than 
,october #a1 #bjah1 for ,,pac providers 
described in clauses 7ii71 7iii71 and   
7iv7 of subsection 7a77#b77;,a71 and    
,january #a1 #bjai1 for ,,pac providers 
described in clause 7i7 of such         
subsection1 the ,secretary shall match  
claims data with assessment data        
pursuant to this section for purposes of
 assessing prior service use and        
concurrent service use1 such as         
antecedent hospital or ,,pac provider   

use1 and may use such matched data for  
such other uses as the ,secretary       
determines appropriate4  7#c7           
,replacement of certain existing data   
,in the case of patient assessment data 
being used with respect to a ,,pac      
assessment instrument that duplicates or
 overlaps with standardized patient     
assessment data within a category       
described in paragraph 7#a71 the        
,secretary shall1 as soon as            
practicable1 revise or replace such     
existing data with the standardized     
data4  7#d7 ,clarification ,standardized
 patient assessment data submitted      
pursuant to this subsection shall not be
 used to require individuals to be      
provided post-acute care by a specific  
type of ,,pac provider in order for such
 care to be eligible for payment under  
this title4  7c7 ,quality measures  7#a7
 ,requirement for reporting quality     
measures ,not later than the specified  
application date1 as applicable to      
measures and ,,pac providers1 the       

,secretary shall specify quality        
measures on which ,,pac providers are   
required under the applicable reporting 
provisions to submit standardized       
patient assessment data described in    
subsection 7b77#a7 and other necessary  
data specified by the ,secretary4 ,such 
measures shall be with respect to at    
least the following domains3  7,a7      
,functional status1 cognitive function1 
and changes in function and cognitive   
function4  7,b7 ,skin integrity and     
changes in skin integrity4  7,c7        
,medication reconciliation4  7,d7       
,incidence of major falls4  7,e7        
,accurately communicating the existence 
of and providing for the transfer of    
health information and care preferences 
of an individual to the individual1     
family caregiver of the individual1 and 
providers of services furnishing items  
and services to the individual1 when the
 individual transitions--  7i7 from a   
hospital or critical access hospital to 
another applicable setting1 including a 

,,pac provider or the home of the       
individual2 or  7ii7 from a ,,pac       
provider to another applicable setting1 
including a different ,,pac provider1 a 
hospital1 a critical access hospital1 or
 the home of the individual4  7#b7      
,reporting through ,,pac assessment     
instruments  7,a7 ,in general ,to the   
extent possible1 the ,secretary shall   
require such reporting by a ,,pac       
provider of quality measures under      
paragraph 7#a7 through the use of a     
,,pac assessment instrument and shall   
modify such ,,pac assessment instrument 
as necessary to enable the use of such  
instrument with respect to such quality 
measures4  7,b7 ,limitation ,the        
,secretary may not make significant     
modifications to a ,,pac assessment     
instrument more than once per calendar  
year or fiscal year1 as applicable1     
unless the ,secretary publishes in the  
,federal ,register a justification for  
such significant modification4  7#c7    
,adjustments  7,a7 ,in general ,the     

,secretary shall consider applying      
adjustments to the quality measures     
under this subsection taking into       
consideration the studies under section 
#b7;d7 of the ,,impact ,act of #bjad4   
7,b7 ,risk adjustment ,such quality     
measures shall be risk adjusted1 as     
determined appropriate by the           
,secretary4  7d7 ,resource use and other
 measures  7#a7 ,requirement for        
resource use and other measures ,not    
later than the specified application    
date1 as applicable to measures and     
,,pac providers1 the ,secretary shall   
specify resource use and other measures 
on which ,,pac providers are required   
under the applicable reporting          
provisions to submit any necessary data 
specified by the ,secretary1 which may  
include standardized assessment data in 
addition to claims data4 ,such measures 
shall be with respect to at least the   
following domains3  7,a7 ,resource use  
measures1 including total estimated     
,medicare spending per beneficiary4     

7,b7 ,discharge to community4  7,c7     
,measures to reflect all-condition      
risk-adjusted potentially preventable   
hospital readmission rates4  7#b7       
,aligning methodology adjustments for   
resource use measures  7,a7 ,period of  
time ,with respect to the period of time
 used for calculating measures under    
paragraph 7#a77;,a71 the ,secretary     
shall1 to the extent the ,secretary     
determines appropriate1 align resource  
use with the methodology used for       
purposes of section                     
#ahhf7o77#b77;,b77ii74  7,b7 ,geographic
 and other adjustments ,the ,secretary  
shall standardize measures with respect 
to the domain described in paragraph    
7#a77;,a7 for geographic payment rate   
differences and payment differentials   
7and other adjustments1 as applicable7  
consistent with the methodology         
published in the ,federal ,register on  
,august #ah1 #bjaa 7#gf ,fed4 ,reg4     
#eafbd through #eafbf71 or any          
subsequent modifications made to the    

methodology4  7,c7 ,medicare spending   
per beneficiary ,the ,secretary shall   
adjust1 as appropriate1 measures with   
respect to the domain described in      
paragraph 7#a77;,a7 for the factors     
applied under section                   
#ahhf7o77#b77;,b77ii74  7#c7            
,adjustments  7,a7 ,in general ,the     
,secretary shall consider applying      
adjustments to the resource use and     
other measures specified under this     
subsection with respect to the domain   
described in paragraph 7#a77;,a71 taking
 into consideration the studies under   
section #b7;d7 of the ,,impact ,act of  
#bjad4  7,b7 ,risk adjustment ,such     
resource use and other measures shall be
 risk adjusted1 as determined           
appropriate by the ,secretary4  7e7     
,measurement implementation phases2     
,selection of quality measures and      
resource use and other measures  7#a7   
,measurement implementation phases ,in  
the case of quality measures specified  
under subsection 7c77#a7 and resource   

use and other measures specified under  
subsection 7d77#a71 the provisions of   
this section shall be implemented in    
accordance with the following phases3   
7,a7 ,initial implementation phase ,the 
initial implementation phase1 with      
respect to such a measure1 shall1 in    
accordance with subsections 7c7 and 7d71
 as applicable1 consist of--  7i7       
measure specification1 including        
informing the public of the measure's   
numerator1 denominator1 exclusions1 and 
any other aspects the ,secretary        
determines necessary2  7ii7 data        
collection1 including1 in the case of   
quality measures1 requiring ,,pac       
providers to report data elements needed
 to calculate such a measure2 and  7iii7
 data analysis1 including1 in the case  
of resource use and other measures1 the 
use of claims data to calculate such a  
measure4  7,b7 ,second implementation   
phase ,the second implementation phase1 
with respect to such a measure1 shall   
consist of the provision of feedback    

reports to ,,pac providers1 in          
accordance with subsection 7f74  7,c7   
,third implementation phase ,the third  
implementation phase1 with respect to   
such a measure1 shall consist of public 
reporting of ,,pac providers'           
performance on such measure in          
accordance with subsection 7g74  7#b7   
,consensus-based entity  7,a7 ,in       
general ,subject to subparagraph 7,b71  
each measure specified by the ,secretary
 under this section shall be endorsed by
 the entity with a contract under       
section #ahij7;a74  7,b7 ,exception ,in 
the case of a specified area or medical 
topic determined appropriate by the     
,secretary for which a feasible and     
practical measure has not been endorsed 
by the entity with a contract under     
section #ahij7;a71 the ,secretary may   
specify a measure that is not so        
endorsed as long as due consideration is
 given to measures that have been       
endorsed or adopted by a consensus      
organization identified by the          

,secretary4  7#c7 ,treatment of         
application of pre-rulemaking process   
7measure applications partnership       
process7  7,a7 ,in general ,subject to  
subparagraph 7,b71 the provisions of    
section #ahij;,a shall apply in the case
 of a quality measure specified under   
subsection 7c7 or a resource use or     
other measure specified under subsection
 7d74  7,b7 ,exceptions  7i7 ,expedited 
procedures ,for purposes of satisfying  
subparagraph 7,a71 the ,secretary may   
use expedited procedures1 such as ad-hoc
 reviews1 as necessary1 in the case of a
 quality measure specified under        
subsection 7c7 or a resource use or     
other measure specified in subsection   
7d7 required with respect to data       
submissions under the applicable        
reporting provisions during the #a-year 
period before the specified application 
date applicable to such a measure and   
provider involved4  7ii7 ,option to     
waive provisions ,the ,secretary may    
waive the application of the provisions 

of section #ahij;,a in the case of a    
quality measure or resource use or other
 measure described in clause 7i71 if the
 application of such provisions         
7including through the use of an        
expedited procedure described in such   
clause7 would result in the inability of
 the ,secretary to satisfy any deadline 
specified in this section with respect  
to such measure4  7f7 ,feedback reports 
to ,,pac providers  7#a7 ,in general    
,beginning one year after the specified 
application date1 as applicable to ,,pac
 providers and quality measures and     
resource use and other measures under   
this section1 the ,secretary shall      
provide confidential feedback reports to
 such ,,pac providers on the performance
 of such providers with respect to such 
measures required under the applicable  
provisions4  7#b7 ,frequency ,to the    
extent feasible1 the ,secretary shall   
provide feedback reports described in   
paragraph 7#a7 not less frequently than 
on a quarterly basis4 ,notwithstanding  

the previous sentence1 with respect to  
measures described in such paragraph    
that are reported on an annual basis1   
the ,secretary may provide such feedback
 reports on an annual basis4  7g7       
,public reporting of ,,pac provider     
performance  7#a7 ,in general ,subject  
to the succeeding paragraphs of this    
subsection1 the ,secretary shall provide
 for public reporting of ,,pac provider 
performance on quality measures under   
subsection 7c77#a7 and the resource use 
and other measures under subsection     
7d77#a71 including by establishing      
procedures for making available to the  
public information regarding the        
performance of individual ,,pac         
providers with respect to such measures4
  7#b7 ,opportunity to review ,the      
procedures under paragraph 7#a7 shall   
ensure1 including through a process     
consistent with the process applied     
under section                           
#ahhf7;b77#c77;,b77viii77,,vii7 for     
similar purposes1 that a ,,pac provider 

has the opportunity to review and submit
 corrections to the data and information
 that is to be made public with respect 
to the provider prior to such data being
 made public4  7#c7 ,timing ,such       
procedures shall provide that the data  
and information described in paragraph  
7#a71 with respect to a measure and     
,,pac provider1 is made publicly        
available beginning not later than two  
years after the specified application   
date applicable to such a measure and   
provider4  7#d7 ,coordination with      
existing programs ,such procedures shall
 provide that data and information      
described in paragraph 7#a7 with respect
 to quality measures and resource use   
and other measures under subsections    
7c77#a7 and 7d77#a7 shall be made       
publicly available consistent with the  
following provisions3  7,a7 ,in the case
 of home health agencies1 section       
#ahie7;b77#c77;,b77v77,,iii74  7,b7 ,in 
the case of skilled nursing facilities1 
sections #ahai7;i7 and #aiai7;i74  7,c7 

,in the case of inpatient rehabilitation
 facilities1 section #ahhf7;j77#g77;,e74
  7,d7 ,in the case of long-term care   
hospitals1 section #ahhf7m77#e77;,e74   
7h7 ,removing1 suspending1 or adding    
measures  7#a7 ,in general ,the         
,secretary may remove1 suspend1 or add a
 quality measure or resource use or     
other measure described in subsection   
7c77#a7 or 7d77#a71 so long as1 subject 
to paragraph 7#b71 the ,secretary       
publishes in the ,federal ,register     
7with a notice and comment period7 a    
justification for such removal1         
suspension1 or addition4  7#b7          
,exception ,in the case of such a       
quality measure or resource use or other
 measure for which there is a reason to 
believe that the continued collection of
 such measure raises potential safety   
concerns or would cause other unintended
 consequences1 the ,secretary may       
promptly suspend or remove such measure 
and satisfy paragraph 7#a7 by publishing
 in the ,federal ,register a            

justification for such suspension or    
removal in the next rulemaking cycle    
following such suspension or removal4   
7i7 ,use of standardized assessment     
data1 quality measures1 and resource use
 and other measures ,to inform discharge
 planning and incorporate patient       
preference  7#a7 ,in general ,not later 
than ,january #a1 #bjaf1 and            
periodically thereafter 7but not less   
frequently than once every #e years71   
the ,secretary shall promulgate         
regulations to modify conditions of     
participation and subsequent            
interpretive guidance applicable to     
,,pac providers1 hospitals1 and critical
 access hospitals4 ,such regulations and
 interpretive guidance shall require    
such providers to take into account     
quality1 resource use1 and other        
measures under the applicable reporting 
provisions 7which1 as available1 shall  
include measures specified under        
subsections 7c7 and 7d71 and other      
relevant measures7 in the discharge     

planning process4 ,specifically1 such   
regulations and interpretive guidance   
shall address the settings to which a   
patient may be discharged in order to   
assist subsection 7d7 hospitals1        
critical access hospitals1 hospitals    
described in section                    
#ahhf7;d77#a77;,b77v71 ,,pac providers1 
patients1 and families of such patients 
with discharge planning from inpatient  
settings1 including such hospitals1 and 
from ,,pac provider settings4 ,in       
addition1 such regulations and          
interpretive guidance shall include     
procedures to address--  7,a7 treatment 
preferences of patients2 and  7,b7 goals
 of care of patients4  7#b7 ,discharge  
planning ,all requirements applied      
pursuant to paragraph 7#a7 shall be used
 to help inform and mandate the         
discharge planning process4  7#c7       
,clarification ,such regulations shall  
not require an individual to be provided
 post-acute care by a specific type of  
,,pac provider in order for such care to

 be eligible for payment under this     
title4  7j7 ,stakeholder input ,before  
the initial rulemaking process to       
implement this section1 the ,secretary  
shall allow for stakeholder input1 such 
as through town halls1 open door forums1
 and mail-box submissions4  7k7 ,funding
 ,for purposes of carrying out this     
section1 the ,secretary shall provide   
for the transfer to the ,centers for    
,medicare  ,medicaid ,services ,program 
,management ,account1 from the ,federal 
,hospital ,insurance ,trust ,fund under 
section #ahag and the ,federal          
,supplementary ,medical ,insurance      
,trust ,fund under section #ahda1 in    
such proportion as the ,secretary       
determines appropriate1 of #acj1jjj1jjj4
 ,fifty percent of such amount shall be 
available on the date of the enactment  
of this section and fifty percent of    
such amount shall be equally            
proportioned for each of fiscal years   
#bjae through #bjai4 ,such sums shall   
remain available until expended4  7l7   

,limitation ,there shall be no          
administrative or judicial review under 
sections #ahfi and #ahgh or otherwise of
 the specification of standardized      
patient assessment data required1 the   
determination of measures1 and the      
systems to report such standardized data
 under this section4  7m7               
,non-,application of ,paperwork         
,reduction ,act ,chapter #ce of title   
#dd1 ,united ,states ,code 7commonly    
referred to as the ,paperwork ,reduction
 ,act of #aiie7 shall not apply to this 
section and the sections referenced in  
subsection 7a77#b77;,b7 that require    
modification in order to achieve the    
standardization of patient assessment   
data4  4  7b7 ,studies of alternative   
,,pac payment models  7#a7 ,med,p,a,c   
,using data from the ,post-,acute       
,payment ,reform ,demonstration         
authorized under section #ejjh of the   
,deficit ,reduction ,act of #bjje       
7,public ,law #aji-aga7 or other data1  
as available1 not later than ,june #cj1 

#bjaf1 the ,medicare ,payment ,advisory 
,commission shall submit to ,congress a 
report that evaluates and recommends    
features of ,,pac payment systems 7as   
defined in section #ahii;,b7a77#b77;,d7 
of the ,social ,security ,act1 as added 
by subsection 7a77 that establish1 or a 
unified post-acute care payment system  
under title ,,xviii of the ,social      
,security ,act that establishes1 payment
 rates according to characteristics of  
individuals 7such as cognitive ability1 
functional status1 and impairments7     
instead of according to the post-acute  
care setting where the ,medicare        
beneficiary involved is treated4 ,to the
 extent feasible1 such report shall     
consider the impacts of moving from     
,,pac payment systems 7as defined in    
subsection 7a77#b77;,d7 of such section 
#ahii;,b7 in existence as of the date of
 the enactment of this ,act to new      
post-acute care payment systems under   
title ,,xviii of the ,social ,security  
,act4  7#b7 ,recommendations for ,,pac  

prospective payment  7,a7 ,report by    
,secretary ,not later than #b years     
after the date by which the ,secretary  
of ,health and ,human ,services has     
collected #b years of data on quality   
measures under subsection 7c7 of section
 #ahii;,b1 as added by subsection 7a71  
the ,secretary shall1 in consultation   
with the ,medicare ,payment ,advisory   
,commission and appropriate             
stakeholders1 submit to ,congress a     
report1 including--  7i7 recommendations
 and a technical prototype1 on a        
post-acute care prospective payment     
system under title ,,xviii of the       
,social ,security ,act that would--     
7,i7 in lieu of the rates that would    
otherwise apply under ,,pac payment     
systems 7as defined in subsection       
7a77#b77;,d7 of such section #ahii;,b71 
base payments under such title1 with    
respect to items and services furnished 
to an individual by a ,,pac provider 7as
 defined in subsection 7a77#b77;,a7 of  
such section71 according to individual  

characteristics 7such as cognitive      
ability1 functional status1 and         
impairments7 of such individual instead 
of the post-acute care setting in which 
the individual is furnished such items  
and services2  7,,ii7 account for the   
clinical appropriateness of items and   
services so furnished and ,medicare     
beneficiary outcomes2  7,,iii7 be       
designed to incorporate 7or otherwise   
account for7 standardized patient       
assessment data under section #ahii;,b2 
and  7,,iv7 further clinical            
integration1 such as by motivating      
greater coordination around a single    
condition or procedure to integrate     
hospital systems with ,,pac providers   
7as so defined74  7ii7 recommendations  
on which ,medicare fee-for-service      
regulations for post-acute care payment 
systems under title ,,xviii of the      
,social ,security ,act should be altered
 7such as the skilled nursing facility  
#c-;day stay and inpatient              
rehabilitation facility #fj percent     

rule72  7iii7 an analysis of the impact 
of the recommended payment system       
described in clause 7i7 on ,medicare    
beneficiary cost-sharing1 access to     
care1 and choice of setting2  7iv7 a    
projection of any potential reduction in
 expenditures under title ,,xviii of the
 ,social ,security ,act that may be     
attributable to the application of the  
recommended payment system described in 
clause 7i72 and  7v7 a review of the    
value of subsection 7d7 hospitals 7as   
defined in section #ahhf7;d77#a77;,b7 of
 the ,social ,security ,act 7#db        
,u4,s4,c4 #acieww7d77#a77;,b771         
hospitals described in section          
#ahhf7;d77#a77;,b77v7 of such ,act 7#db 
,u4,s4,c4 #acieww7d77#a77;,b77v771 and  
critical access hospitals described in  
section #ahbj7;c77#b77;,b7 of such ,act 
7#db ,u4,s4,c4 #acie;i-#d7;c77#b77;,b77 
collecting and reporting to the         
,secretary standardized patient         
assessment data with respect to         
inpatient hospital services furnished by

 such a hospital or critical access     
hospital to individuals who are entitled
 to benefits under part ,a of title     
,,xviii of such ,act or1 as appropriate1
 enrolled for benefits under part ,b of 
such title4  7,b7 ,report by ,med,p,a,c 
,not later than the first ,june #cjth   
following the date on which the report  
is required under subparagraph 7,a71 the
 ,medicare ,payment ,advisory           
,commission shall submit to ,congress a 
report1 including recommendations and a 
technical prototype1 on a post-acute    
care prospective payment system under   
title ,,xviii of the ,social ,security  
,act that would satisfy the criteria    
described in subparagraph 7,a74  7#c7   
,medicare beneficiary defined ,for      
purposes of this subsection1 the term   
,medicare beneficiary has the meaning   
given such term in section              
#ahii;,b7a77#b7 of the ,social ,security
 ,act1 as added by subsection 7a74  7c7 
,payment consequences under the         
applicable reporting provisions  7#a7   

,home health agencies ,section          
#ahie7;b77#c77;,b77v7 of the ,social    
,security ,act 7#db ,u4,s4,c4           
#acie;fff7b77#c77;,b77v77 is amended--  
7,a7 in subclause 7,i71 by striking     
subclause 7,,ii7 and inserting          
subclauses 7,,ii7 and 7,,iv72  7,b7 in  
subclause 7,,ii71 by striking ,for #bjjg
 and inserting ,subject to subclause    
7,v71 for #bjjg2  7,c7 in subclause     
7,,iii71 by inserting and subclause     
7,,iv77aa7 after subclause 7,,ii72 and  
7,d7 by adding at the end the following 
new subclauses3  7,,iv7 ,submission of  
additional data  7aa7 ,in general ,for  
the year beginning on the specified     
application date 7as defined in         
subsection 7a77#b77;,e7 of section      
#ahii;,b71 as applicable with respect to
 home health agencies and quality       
measures under subsection 7c77#a7 of    
such section and measures under         
subsection 7d77#a7 of such section1 and 
each subsequent year1 in addition to the
 data described in subclause 7,,ii71    

each home health agency shall submit to 
the ,secretary data on such quality     
measures and any necessary data         
specified by the ,secretary under such  
subsection 7d77#a74  7bb7 ,standardized 
patient assessment data ,for #bjai and  
each subsequent year1 in addition to    
such data described in item 7aa71 each  
home health agency shall submit to the  
,secretary standardized patient         
assessment data required under          
subsection 7b77#a7 of section #ahii;,b4 
7cc7 ,submission ,data shall be         
submitted under items 7aa7 and 7bb7 in  
the form and manner1 and at the time1   
specified by the ,secretary for purposes
 of this clause4  7,v7 ,non-duplication 
,to the extent data submitted under     
subclause 7,,iv7 duplicates other data  
required to be submitted under subclause
 7,,ii71 the submission of such data    
under subclause 7,,iv7 shall be in lieu 
of the submission of such data under    
subclause 7,,ii74 ,the previous sentence
 shall not apply insofar as the         

,secretary determines it is necessary to
 avoid a delay in the implementation of 
section #ahii;,b1 taking into account   
the different specified application     
dates under subsection 7a77#b77;,e7 of  
such section4  4  7#b7 ,inpatient       
rehabilitation facilities ,section      
#ahhf7;j77#g7 of the ,social ,security  
,act 7#db ,u4,s4,c4 #acieww7j77#g77 is  
amended--  7,a7 in subparagraph 7,a77i71
 by striking subparagraph 7,c7 and      
inserting subparagraphs 7,c7 and 7,f72  
7,b7 in subparagraph 7,c71 by striking  
,for fiscal year #bjad and each         
subsequent rate year and inserting      
,subject to subparagraph 7,g71 for      
fiscal year #bjad and each subsequent   
fiscal year2  7,c7 in subparagraph 7,e71
 by inserting and subparagraph 7,f77i7  
after subparagraph 7,c72 and  7,d7 by   
adding at the end the following new     
subparagraphs3  7,f7 ,submission of     
additional data  7i7 ,in general ,for   
the fiscal year beginning on the        
specified application date 7as defined  

in subsection 7a77#b77;,e7 of section   
#ahii;,b71 as applicable with respect to
 inpatient rehabilitation facilities and
 quality measures under subsection      
7c77#a7 of such section and measures    
under subsection 7d77#a7 of such        
section1 and each subsequent fiscal     
year1 in addition to such data on the   
quality measures described in           
subparagraph 7,c71 each rehabilitation  
facility shall submit to the ,secretary 
data on the quality measures under such 
subsection 7c77#a7 and any necessary    
data specified by the ,secretary under  
such subsection 7d77#a74  7ii7          
,standardized patient assessment data   
,for fiscal year #bjai and each         
subsequent fiscal year1 in addition to  
such data described in clause 7i71 each 
rehabilitation facility shall submit to 
the ,secretary standardized patient     
assessment data required under          
subsection 7b77#a7 of section #ahii;,b4 
7iii7 ,submission ,such data shall be   
submitted in the form and manner1 and at

 the time1 specified by the ,secretary  
for purposes of this subparagraph4  7,g7
 ,non-duplication ,to the extent data   
submitted under subparagraph 7,f7       
duplicates other data required to be    
submitted under subparagraph 7,c71 the  
submission of such data under           
subparagraph 7,f7 shall be in lieu of   
the submission of such data under       
subparagraph 7,c74 ,the previous        
sentence shall not apply insofar as the 
,secretary determines it is necessary to
 avoid a delay in the implementation of 
section #ahii;,b1 taking into account   
the different specified application     
dates under subsection 7a77#b77;,e7 of  
such section4  4  7#c7 ,long-term care  
hospitals ,section #ahhf7m77#e7 of the  
,social ,security ,act 7#db ,u4,s4,c4   
#acieww7m77#e77 is amended--  7,a7 in   
subparagraph 7,a77i71 by striking       
subparagraph 7,c7 and inserting         
subparagraphs 7,c7 and 7,f72  7,b7 in   
subparagraph 7,c71 by striking ,for rate
 year and inserting ,subject to         

subparagraph 7,g71 for rate year2  7,c7 
in subparagraph 7,e71 by inserting and  
subparagraph 7,f77i7 after subparagraph 
7,c72 and  7,d7 by adding at the end the
 following new subparagraphs3  7,f7     
,submission of additional data  7i7 ,in 
general ,for the rate year beginning on 
the specified application date 7as      
defined in subsection 7a77#b77;,e7 of   
section #ahii;,b71 as applicable with   
respect to long-term care hospitals and 
quality measures under subsection       
7c77#a7 of such section and measures    
under subsection 7d77#a7 of such        
section1 and each subsequent rate year1 
in addition to the data on the quality  
measures described in subparagraph 7,c71
 each long-term care hospital 7other    
than a hospital classified under        
subsection 7d77#a77;,b77iv77,,ii77 shall
 submit to the ,secretary data on the   
quality measures under such subsection  
7c77#a7 and any necessary data specified
 by the ,secretary under such subsection
 7d77#a74  7ii7 ,standardized patient   

assessment data ,for rate year #bjai and
 each subsequent rate year1 in addition 
to such data described in clause 7i71   
each long-term care hospital 7other than
 a hospital classified under subsection 
7d77#a77;,b77iv77,,ii77 shall submit to 
the ,secretary standardized patient     
assessment data required under          
subsection 7b77#a7 of section #ahii;,b4 
7iii7 ,submission ,such data shall be   
submitted in the form and manner1 and at
 the time1 specified by the ,secretary  
for purposes of this subparagraph4  7,g7
 ,non-duplication ,to the extent data   
submitted under subparagraph 7,f7       
duplicates other data required to be    
submitted under subparagraph 7,c71 the  
submission of such data under           
subparagraph 7,f7 shall be in lieu of   
the submission of such data under       
subparagraph 7,c74 ,the previous        
sentence shall not apply insofar as the 
,secretary determines it is necessary to
 avoid a delay in the implementation of 
section #ahii;,b1 taking into account   

the different specified application     
dates under subsection 7a77#b77;,e7 of  
such section4  4  7#d7 ,skilled nursing 
facilities  7,a7 ,in general ,paragraph 
7#f7 of section #ahhh7;e7 of the ,social
 ,security ,act 7#db ,u4,s4,c4          
#acieyy7e77 is amended to read as       
follows3  7#f7 ,reporting of assessment 
and quality data  7,a7 ,reduction in    
update for failure to report  7i7 ,in   
general ,for fiscal years beginning with
 fiscal year #bjah1 in the case of a    
skilled nursing facility that does not  
submit data1 as applicable1 in          
accordance with subclauses 7,,ii7 and   
7,,iii7 of subparagraph 7,b77i7 with    
respect to such a fiscal year1 after    
determining the percentage described in 
paragraph 7#e77;,b77i71 and after       
application of paragraph 7#e77;,b77ii71 
the ,secretary shall reduce such        
percentage for payment rates during such
 fiscal year by #b percentage points4   
7ii7 ,special rule ,the application of  
this subparagraph may result in the     

percentage described in paragraph       
7#e77;,b77i71 after application of      
paragraph 7#e77;,b77ii71 being less than
 #j4j for a fiscal year1 and may result 
in payment rates under this subsection  
for a fiscal year being less than such  
payment rates for the preceding fiscal  
year4  7iii7 ,noncumulative application 
,any reduction under clause 7i7 shall   
apply only with respect to the fiscal   
year involved and the ,secretary shall  
not take into account such reduction in 
computing the payment amount under this 
subsection for a subsequent fiscal year4
  7,b7 ,assessment and measure data  7i7
 ,in general ,a skilled nursing         
facility1 or a facility 7other than a   
critical access hospital7 described in  
paragraph 7#g77;,b71 shall submit to the
 ,secretary1 in a manner and within the 
timeframes prescribed by the            
,secretary--  7,i7 subject to clause    
7iii71 the resident assessment data     
necessary to develop and implement the  
rates under this subsection2  7,,ii7 for

 fiscal years beginning on or after the 
specified application date 7as defined  
in subsection 7a77#b77;,e7 of section   
#ahii;,b71 as applicable with respect to
 skilled nursing facilities and quality 
measures under subsection 7c77#a7 of    
such section and measures under         
subsection 7d77#a7 of such section1 data
 on such quality measures under such    
subsection 7c77#a7 and any necessary    
data specified by the ,secretary under  
such subsection 7d77#a72 and  7,,iii7   
for fiscal years beginning on or after  
,october #a1 #bjah1 standardized patient
 assessment data required under         
subsection 7b77#a7 of section #ahii;,b4 
7ii7 ,use of standard instrument ,for   
purposes of meeting the requirement     
under clause 7i71 a skilled nursing     
facility1 or a facility 7other than a   
critical access hospital7 described in  
paragraph 7#g77;,b71 may submit the     
resident assessment data required under 
section #ahai7;b77#c71 using the        
standard instrument designated by the   

,state under section #ahai7;e77#e74     
7iii7 ,non-duplication ,to the extent   
data submitted under subclause 7,,ii7 or
 7,,iii7 of clause 7i7 duplicates other 
data required to be submitted under     
clause 7i77,i71 the submission of such  
data under such a subclause shall be in 
lieu of the submission of such data     
under clause 7i77,i74 ,the previous     
sentence shall not apply insofar as the 
,secretary determines it is necessary to
 avoid a delay in the implementation of 
section #ahii;,b1 taking into account   
the different specified application     
dates under subsection 7a77#b77;,e7 of  
such section4  4  7,b7 ,funding for     
nursing home compare website ,section   
#ahai7;i7 of the ,social ,security ,act 
7#db ,u4,s4,c4 #acie;i-#c7;i77 is       
amended by adding at the end the        
following new paragraph3  7#c7 ,funding 
,the ,secretary shall transfer to the   
,centers for ,medicare  ,medicaid       
,services ,program ,management ,account1
 from the ,federal ,hospital ,insurance 

,trust ,fund under section #ahag a      
one-time allocation of #aa1jjj1jjj4 ,the
 amount shall be available on the date  
of the enactment of this paragraph4     
,such sums shall remain available until 
expended4 ,such sums shall be used to   
implement section #aabh;,i7g74  4  7d7  
,improving payment accuracy under the   
,,pac payment systems and other         
,medicare payment systems  7#a7 ,studies
 and reports of effect of certain       
information on quality and resource use 
7,a7 ,study using existing ,medicare    
data  7i7 ,study ,the ,secretary of     
,health and ,human ,services 7in this   
subsection referred to as the           
,secretary7 shall conduct a study that  
examines the effect of individuals'     
socioeconomic status on quality measures
 and resource use and other measures for
 individuals under the ,medicare program
 under title ,,xviii of the ,social     
,security ,act 7#db ,u4,s4,c4 #acie et  
seq47 7such as to recognize that less   
healthy individuals may require more    

intensive interventions74 ,the study    
shall use information collected on such 
individuals in carrying out such        
program1 such as urban and rural        
location1 eligibility for ,medicaid     
under title ,,xix of such ,act 7#db     
,u4,s4,c4 #acif et seq47 7recognizing   
and accounting for varying ,medicaid    
eligibility across ,states71 and        
eligibility for benefits under the      
supplemental security income 7,,ssi7    
program4 ,the ,secretary shall carry out
 this paragraph acting through the      
,assistant ,secretary for ,planning and 
,evaluation4  7ii7 ,report ,not later   
than #b years after the date of the     
enactment of this ,act1 the ,secretary  
shall submit to ,congress a report on   
the study conducted under clause 7i74   
7,b7 ,study using other data  7i7 ,study
 ,the ,secretary shall conduct a study  
that examines the impact of risk        
factors1 such as those described in     
section #ahdh7p77#c7 of the ,social     
,security ,act 7#db ,u4,s4,c4           

#aciew-#d7p77#c771 race1 health         
literacy1 limited ,english proficiency  
7,,lep71 and ,medicare beneficiary      
activation1 on quality measures and     
resource use and other measures under   
the ,medicare program 7such as to       
recognize that less healthy individuals 
may require more intensive              
interventions74 ,in conducting such     
study the ,secretary may use existing   
,federal data and collect such          
additional data as may be necessary to  
complete the study4  7ii7 ,report ,not  
later than #e years after the date of   
the enactment of this ,act1 the         
,secretary shall submit to ,congress a  
report on the study conducted under     
clause 7i74  7,c7 ,examination of data  
in conducting studies ,in conducting the
 studies under subparagraphs 7,a7 and   
7,b71 the ,secretary shall examine what 
non-,medicare data sets1 such as data   
from the ,american ,community ,survey   
7,,acs71 can be useful in conducting the
 types of studies under such paragraphs 

and how such data sets that are         
identified as useful can be coordinated 
with ,medicare administrative data in   
order to improve the overall data set   
available to do such studies and for the
 administration of the ,medicare        
program4  7,d7 ,recommendations to      
account for information in payment      
adjustment mechanisms ,if the studies   
conducted under subparagraphs 7,a7 and  
7,b7 find a relationship between the    
factors examined in the studies and     
quality measures and resource use and   
other measures1 then the ,secretary     
shall also provide recommendations for  
how the ,centers for ,medicare          
,medicaid ,services should--  7i7 obtain
 access to the necessary data 7if such  
data is not already being collected7 on 
such factors1 including recommendations 
on how to address barriers to the       
,centers in accessing such data2 and    
7ii7 account for such factors--  7,i7 in
 quality measures1 resource use         
measures1 and other measures under title

 ,,xviii of the ,social ,security ,act  
7including such measures specified under
 subsections 7c7 and 7d7 of section     
#ahii;,b of such ,act1 as added by      
subsection 7a772 and  7,,ii7 in         
determining payment adjustments based on
 such measures in other applicable      
provisions of such title4  7,e7 ,funding
 ,there are hereby appropriated to the  
,secretary from the ,federal ,hospital  
,insurance ,trust ,fund under section   
#ahag of the ,social ,security ,act 7#db
 ,u4,s4,c4 #acie;i7 and the ,federal    
,supplementary ,medical ,insurance      
,trust ,fund under section #ahda of such
 ,act 7#db ,u4,s4,c4 #aciet7 7in        
proportions determined appropriate by   
the ,secretary7 to carry out this       
paragraph #f1jjj1jjj1 to remain         
available until expended4  7#b7 ,,cms   
activities  7,a7 ,in general ,taking    
into account the relevant studies       
conducted and recommendations made in   
reports under paragraph 7#a7 and1 as    
appropriate1 other information1         

including information collected before  
completion of such studies and          
recommendations1 the ,secretary1 on an  
ongoing basis1 shall1 as the ,secretary 
determines appropriate and based on an  
individual's health status and other    
factors--  7i7 assess appropriate       
adjustments to quality measures1        
resource use measures1 and other        
measures under title ,,xviii of the     
,social ,security ,act 7#db ,u4,s4,c4   
#acie et seq47 7including measures      
specified in subsections 7c7 and 7d7 of 
section #ahii;,b of such ,act1 as added 
by subsection 7a772 and  7ii7 assess and
 implement appropriate adjustments to   
payments under such title based on      
measures described in clause 7i74  7,b7 
,accessing data ,the ,secretary shall   
collect or otherwise obtain access to   
the data necessary to carry out this    
paragraph through existing and new data 
sources4  7,c7 ,periodic analyses ,the  
,secretary shall carry out periodic     
analyses1 at least every #c years1 based

 on the factors referred to in          
subparagraph 7,a7 so as to monitor      
changes in possible relationships4  7,d7
 ,funding ,there are hereby appropriated
 to the ,secretary from the ,federal    
,hospital ,insurance ,trust ,fund under 
section #ahag of the ,social ,security  
,act 7#db ,u4,s4,c4 #acie;i7 and the    
,federal ,supplementary ,medical        
,insurance ,trust ,fund under section   
#ahda of such ,act 7#db ,u4,s4,c4       
#aciet7 7in proportions determined      
appropriate by the ,secretary7 to carry 
out this paragraph #aj1jjj1jjj1 to      
remain available until expended4  7#c7  
,strategic plan for accessing race and  
ethnicity data ,not later than #ah      
months after the date of the enactment  
of this ,act1 the ,secretary shall      
develop and report to ,congress on a    
strategic plan for collecting or        
otherwise accessing data on race and    
ethnicity for purposes of specifying    
quality measures and resource use and   
other measures under subsections 7c7 and

 7d7 of section #ahii;,b of the ,social 
,security ,act1 as added by subsection  
7a71 and1 as the ,secretary determines  
appropriate1 other similar provisions   
of1 including payment adjustments under1
 title ,,xviii of such ,act 7#db        
,u4,s4,c4 #acie et seq474  #c4 ,hospice 
care  7a7 ,hospice survey requirement   
7#a7 ,in general ,section #ahfa7;dd77#d7
 of the ,social ,security ,act 7#db     
,u4,s4,c4 #aciex7dd77#d77 is amended by 
adding at the end the following new     
subparagraph3  7,c7 ,any entity that is 
certified as a hospice program shall be 
subject to a standard survey by an      
appropriate ,state or local survey      
agency1 or an approved accreditation    
agency1 as determined by the ,secretary1
 not less frequently than once every #cf
 months beginning #f months after the   
date of the enactment of this           
subparagraph and ending ,september #cj1 
#bjbe4  4  7#b7 ,funding ,for purposes  
of carrying out subparagraph 7,c7 of    
section #ahfa7;dd77#d7 of the ,social   

,security ,act 7#db ,u4,s4,c4           
#aciex7dd77#d771 as added by paragraph  
7#a71 there shall be transferred from   
the ,federal ,hospital ,insurance ,trust
 ,fund under section #ahag of such ,act 
7#db ,u4,s4,c4 #acie;i7 to the ,centers 
for ,medicare  ,medicaid ,services      
,program ,management ,account--  7,a7   
#be1jjj1jjj for fiscal years #bjae      
through #bjag1 to be made available for 
such purposes in equal parts for each   
such fiscal year2 and  7,b7 #de1jjj1jjj 
for fiscal years #bjah through #bjbe1 to
 be made available for such purposes in 
equal parts for each such fiscal year4  
7b7 ,hospice program eligibility        
recertification technical correction to 
apply limitation on liability of        
beneficiary rules ,section #ahgi of the 
,social ,security ,act 7#db ,u4,s4,c4   
#aciepp7 is amended by adding at the end
 the following new subsection3  7i7 ,the
 provisions of this section shall apply 
with respect to a denial of a payment   
under this title by reason of section   

#ahad7;a77#g77;,e7 in the same manner as
 such provisions apply with respect to a
 denial of a payment under this title by
 reason of section #ahfb7;a77#a74  4    
7c7 ,revision to requirement for medical
 review of certain hospice care ,section
 #ahad7;a77#g7 of the ,social ,security 
,act 7#db ,u4,s4,c4 #acie;f7a77#g77 is  
amended--  7#a7 in subparagraph 7,c71 by
 striking and at the end2  7#b7 in      
subparagraph 7,d71 in the matter        
preceding clause 7i71 by inserting 7and1
 in the case of clause 7ii71 before the 
date of enactment of subparagraph 7,e77 
after #bjaa2 and  7#c7 by adding at the 
end the following new subparagraph3     
7,e7 on and after the date of enactment 
of this subparagraph1 in the case of    
hospice care provided an individual for 
more than #ahj days by a hospice program
 for which the number of such cases for 
such program comprises more than a      
percent 7specified by the ,secretary7 of
 the total number of all cases of       
individuals provided hospice care by the

 program under this title1 the hospice  
care provided to such individual is     
medically reviewed 7in accordance with  
procedures established by the           
,secretary72 and  4  7d7 ,update of     
hospice aggregate payment cap ,section  
#ahad7;i77#b77;,b7 of the ,social       
,security ,act 7#db ,u4,s4,c4           
#acie;f7i77#b77;,b77 is amended--  7#a7 
by striking 7,b7 ,for purposes and      
inserting 7,b77i7 ,except as provided in
 clause 7ii71 for purposes2 and  7#b7 by
 adding at the end the following3  7ii7 
,for purposes of subparagraph 7,a7 for  
accounting years that end after         
,september #cj1 #bjaf1 and before       
,october #a1 #bjbe1 the cap amount is   
the cap amount under this subparagraph  
for the preceding accounting year       
updated by the percentage update to     
payment rates for hospice care under    
paragraph 7#a77;,c7 for services        
furnished during the fiscal year        
beginning on the ,october #a preceding  
the beginning of the accounting year    

7including the application of any       
productivity or other adjustment under  
clause 7iv7 of that paragraph74  7iii7  
,for accounting years that end after    
,september #cj1 #bjbe1 the cap amount   
shall be computed under clause 7i7 as if
 clause 7ii7 had never applied4  4  7e7 
,medicare ,improvement ,fund ,section   
#ahih of the ,social ,security ,act 7#db
 ,u4,s4,c4 #acie;iii7 is amended--  7#a7
 by amending the heading to read as     
follows3 ,medicare ,improvement ,fund2  
7#b7 by amending subsection 7a7 to read 
as follows3  7a7 ,establishment ,the    
,secretary shall establish under this   
title a ,medicare ,improvement ,fund 7in
 this section referred to as the        
#8,fund'7 which shall be available to   
the ,secretary to make improvements     
under the original ,medicare            
fee-for-service program under parts ,a  
and ,b for individuals entitled to1 or  
enrolled for1 benefits under part or    
enrolled under part ,b including        
adjustments to payments for items and   

services furnished by providers of      
services and suppliers under such       
original ,medicare fee-for-service      
program4  2  7#c7 in subsection 7b77#a71
 by striking during and all that follows
 and inserting during and after fiscal  
year #bjbj1 #aie1jjj1jjj42 and  7#d7 in 
subsection 7b77#b71 by striking from the
 ,federal and all that follows and      
inserting from the ,federal ,hospital   
,insurance ,trust ,fund and the ,federal
 ,supplementary ,medical ,insurance     
,trust ,fund in such proportion as the  
,secretary determines appropriate44     
,passed the ,house of ,representatives  
,september #af1 #bjad4,karen ,l4        
,haas1,clerk