,,ii  #aag? ,,congress  #a/ ,session    
,s4 #begf  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,july #cj1 #bjba,mr4   
,?une 7= himself & ,mr4 ,c>d97 introduc$
 ! foll[+ bill2 :i* 0 read twice &      
ref]r$ to ! ,committee on ,f9ance  ,a   
,,bill  ,to am5d title ,,xviii ( !      
,social ,security ,act to e/abli% a     
program to all[ qualifi$ gr\p practices 
to furni% c]ta9 items & s]vices at      
qualifi$ skill$ nurs+ facilities to     
individuals entitl$ to b5efits "u "p ,a 
& enroll$ "u "p ,b ( ! ,m$ic>e program  
to r$uce unnecess>y hospitalizations1 & 
= o!r purposes4  #a4 ,%ort title ,?is   
,act may be cit$ z ! ,r$uc+ ,unnecess>y 
,s5ior ,hospitalizations ,act ( #bjba or
 ! ,,ru% ,act ( #bjba4  #b4 ,,snf-bas$  
provision ( prev5tive acute c>e &       
hospitalization r$uction program ,title 
,,xviii ( ! ,social ,security ,act is   
am5d$ by add+ at ! end ! foll[+ new     
section3  #ahii;,c4 ,,snf-bas$ provision
 ( prev5tive acute c>e & hospitalization
 r$uction program  7a7 ,e/abli%m5t ,!re 

is e/abli%$ a program to be kn[n z !    
,,snf-bas$ ,provision ( ,prev5tive      
,acute ,c>e & ,hospitalization ,r$uction
 ,program 79 ?is section ref]r$ to z !  
,program71 to be adm9i/]$ by !          
,secret>y1 = purposes ( r$uc+ unnecess>y
 hospitalizations & em]g5cy dep>tm5t    
visits by all[+ qualifi$ gr\p practices 
7z def9$ 9 section #ahgg7;h77#d77 on or 
aft] ,janu>y #a1 #bjbb1 to furni% items 
& s]vices id5tifi$ "u subsection 7b77#c7
 to individuals entitl$ to b5efits "u "p
 ,a & enroll$ "u "p ,b resid+ 9 qualifi$
 skill$ nurs+ facilities4  7b7 ,op]ation
 ( ,program ,"u ! ,program1 ! ,secret>y 
%all provide = ! foll[+3 7#a7           
,c]tification ( skill$ nurs+ facilities 
z qualifi$ skill$ nurs+ facilities "u   
subsection 7c77#a74  7#b7 ,c]tification 
( gr\p practices z qualifi$ gr\p        
practices "u subsection 7c77#b74  7#c7  
,id5tification on an annual basis (     
m9imum requir$1 cl9ically appropriate   
nonsurgical items & s]vices furni%$ at a
 hospital em]g5cy dep>tm5t t may be     

safely furni%$ by a qualifi$ gr\p       
practice at a qualifi$ skill$ nurs+     
facility "u ! ,program & t su* qualifi$ 
gr\p practice %all (f] to furni% "u !   
,program4 ,su* items & s]vices may      
include provid] review ( lab & imag+    
reports = m$ical decision mak+1         
m$ication managem5t1 blood glucose      
managem5t1 behavioral heal? s]vices1 &  
o!r s]vices (f]$ to diagnose or treat l[
 acuity conditions4  7#d7 ,e/abli%m5t ( 
qualifications = nonphysician employees 
:o may furni% su* items & s]vices at a  
qualifi$ skill$ nurs+ facility4 ,su*    
qualifications %all include ! requirem5t
 t su* an employee-- 7,a7 be c]tifi$ 9  
basic life support by a nationally      
recogniz$ specialty bo>d ( c]tification 
or equival5t c]tification bo>d1 9       
accordance ) requirem5ts "u section     
#dhc4bd7;a77#c7 ( title #db1 ,code (    
,f$]al ,regulations 7or any successor   
regulation72 &  7,b7 h-- 7i7 cl9ical    
exp]i5ce furni%+ m$ical c>e-- 7,i7 9 a  
skill$ nurs+ facility2  7,,ii7 9 a      

hospital em]g5cy dep>tm5t sett+2 or     
7,,iii7 z an employee ( a provid] or    
suppli] ( ambulance s]vices2 or  7ii7 a 
c]tification 9 p>am$ic9e4  7#e7 ,paym5t 
"u ?is title = items & s]vices id5tifi$ 
"u p>agraph 7#c7 furni%$ by su* qualifi$
 gr\p practices at su* a facility 9     
am\nts det]m9$ "u subsection 7d74  7c7  
,c]tifications  7#a7 ,qualifi$ skill$   
nurs+ facilities  7,a7 ,9 g5]al ,=      
purposes ( ?is section1 ! ,secret>y %all
 c]tify a skill$ nurs+ facility z a     
qualifi$ skill$ nurs+ facility if !     
facility submits an application 9 a "t &
 mann] specifi$ by ! ,secret>y & meets !
 foll[+ requirem5ts3 7i7 ,! facility has
 on-site diagno/ic equipm5t necess>y = a
 qualifi$ gr\p practice to furni% items 
& s]vices "u ! ,program & real-"t audio 
& visual capabilities z provid$ by !    
agreem5t betwe5 ! facility & ! qualifi$ 
gr\p practice4  7ii7 ,! facility has at 
lea/ "o individual :o meets !           
qualifications describ$ 9 subsection    
7b77#d7 or a physician pres5t #bd h\rs a

 day & #g days a week to "w ) ! qualifi$
 gr\p practice1 9 accordance ) section  
#dhc4ce7;a7 ( title #db1 ,code ( ,f$]al 
,regulations 7or any successor          
regulation74 ,su* individual may be a   
memb] ( ! /aff ( ! qualifi$ skill$ nurs+
 facility or ( ! qualifi$ gr\p practice4
  7iii7 ,! facility ensures t resid5ts (
 su* facility1 ^u ent]+ su* facility1   
are all[$ to specify 9 an advanc$ c>e   
directive or o!rwise docum5t$ 9 !       
individual's records :e!r ! resid5t     
wi%es to receive items & s]vices furni%$
 at ! facility "u ! ,program 9 a case   
:]e communication ) ! resid5t is n      
possible4  7iv7 ,! facility ensures t   
individuals to be furni%$ su* items &   
s]vices "u ! ,program at su* facility h 
! opportunity1 at _! reque/1 to in/ead  
be transport$ to a hospital em]g5cy     
dep>tm5t4  7v7 ,! facility is n "p ( !  
,special ,focus ,facility program ( !   
,c5t]s = ,m$ic>e  ,m$icaid ,s]vices     
7al?\gh ! facility may1 at ! discretion 
( ! ,secret>y1 be a c&idate = selection 

"u su* program74  7,b7 ,requir$         
provision ( s]vices & activities ,no?+ 9
 ?is p>agraph %all affect ! application 
( requirem5ts "u section #ahai7;b77#d71 
relat+ to provision ( s]vices &         
activities1 to a facility4  7#b7        
,qualifi$ gr\p practices ,= purposes (  
?is section1 ! ,secret>y %all c]tify a  
gr\p practice z a qualifi$ gr\p practice
 = a p]iod ( #c ye>s if ! gr\p practice 
submits an application 9 a "t & mann]   
specifi$ by ! ,secret>y & meets ! foll[+
 requirem5ts3 7,a7 ,! gr\p practice (f]s
 to furni% all m9imum requir$ items &   
s]vices id5tifi$ "u subsection 7b77#c7  
"u ! ,program4  7,b7 ,! gr\p practice   
submits a notification to ! ,secret>y   
annually specify+ :i* 7if any7          
additional items & s]vices id5tifi$ "u  
subsection 7b77#c7 = a ye> ! gr\p       
practice w (f] to furni% = su* ye> "u ! 
,program4  7,c7 ,! gr\p practice ensures
 t only individuals :o meet !           
qualifications e/abli%$ "u subsection   
7b77#d7 or a physician :o is "p ( su*   

gr\p practice may furni% su* m9imum     
requir$ items & s]vices & su* additional
 items & s]vices4  7,d7 ,! gr\p         
practice1 z provid$ by ! agreem5t betwe5
 ! facility & ! gr\p practice or "u !   
sup]vision ( ! m$ical director ( !      
facility1 ensures t1 9 ! case :]e su*   
m9imum requir$ items & s]vices or su*   
additional items & s]vices are furni%$  
by su* an individual1 su* individual    
furni%es su* m9imum requir$ items &     
s]vices or additional items & s]vices "u
 ! sup]vision1 ei!r 9-p]son or ?r\gh !  
use ( teleheal? 7n includ+ /ore-&-=w>d  
te*nologies71 (-- 7i7 a physician-- 7,i7
 :o is bo>d c]tifi$ or bo>d eligible 9  
em]g5cy m$ic9e1 family m$ic9e1          
g]iatrics1 or int]nal m$ic9e2 or  7,,ii7
 :o has be5 c]tifi$ by a nationally     
recogniz$ specialty bo>d ( c]tification 
or equival5t c]tification bo>d 9 basic  
life support2  7ii7 a nurse practition] 
:o has be5 c]tifi$ by a nationally      
recogniz$ specialty bo>d ( c]tification 
or equival5t c]tification bo>d 9 basic  

life support2 or  7iii7 a physician     
assi/ant :o has be5 c]tifi$ by a        
nationally recogniz$ specialty bo>d (   
c]tification or equival5t c]tification  
bo>d 9 basic life support4  7,e7 ,)     
respect to any ye> 9 :i* ! qualifi$ gr\p
 practice w\ld p>ticipate 9 ! ,program1 
! ,*ief ,actu>y = ! ,c5t]s = ,m$ic>e    
,m$icaid ,s]vices det]m9es t su*        
p>ticipation dur+ su* ye> w n result 9  
total e/imat$ exp5ditures "u ?is title =
 su* ye> be+ great] ?an total e/imat$   
exp5ditures "u su* title = su* ye> )\t  
su* p>ticipation4  7d7 ,paym5ts &       
treatm5t ( sav+s  7#a7 ,paym5ts  7,a7 ,9
 g5]al ,= #bjbb & ea* subsequ5t ye>1    
paym5ts %all cont9ue to be made to      
qualifi$ gr\p practices & qualifi$      
skill$ nurs+ facilities p>ticipat+ 9 !  
,program "u ! orig9al ,m$ic>e           
fee-=-s]vice program "u p>ts ,a & ,b 9 !
 same mann] z !y w\ld o!rwise be made   
except t su* gr\p practices & skill$    
nurs+ facilities are eligible to receive
 paym5t = %>$ sav+s "u p>agraph 7#b7 if 

!y meet ! requirem5t "u subp>agraph     
7,b77i74  7,b7 ,sav+s requirem5t &      
b5*m>k  7i7 ,det]m9+ sav+s ,9 ea* ye> ( 
! ,program1 a qualifi$ gr\p practice 7& 
any qualifi$ skill$ nurs+ facility      
p>ticipat+ 9 ! ,program t has an        
agreem5t ) ! gr\p practice = ! furni%+ (
 items & s]vices id5tifi$ "u subsection 
7b77#c7 to resid5ts ( ! facility7 %all  
be eligible to receive paym5t = %>$     
sav+s "u p>agraph 7#b7 only if ! e/imat$
 av]age p] capita ,m$ic>e exp5ditures = 
,m$ic>e fee-=-s]vice b5efici>ies = p>ts 
,a & ,b s]vices furni%$ "u ! ,program by
 ! gr\p practice 7& any su* facility71  
adju/$ = b5efici>y *>act]i/ics1 is at   
lea/ ! p]c5t specifi$ by ! ,secret>y    
bel[ ! applicable b5*m>k "u clause 7ii74
 ,! ,secret>y %all det]m9e ! appropriate
 p]c5t describ$ 9 ! prec$+ s5t5ce to    
acc\nt = normal v>iation 9 exp5ditures  
"u ?is title1 bas$ ^u ! numb] ( ,m$ic>e 
fee-=-s]vice b5efici>ies p>ticipat+ 9 ! 
,program4  7ii7 ,e/abli% & update b5*m>k
 ,= ea* qualifi$ gr\p practice 7& any   

qualifi$ skill$ nurs+ facility          
p>ticipat+ 9 ! ,program t has an        
agreem5t ) ! gr\p practice = ! furni%+ (
 items & s]vices id5tifi$ "u subsection 
7b77#c7 to resid5ts ( ! facility7 !     
,secret>y %all e/imate a s+le b5*m>k =  
ea* ye> t is applicable to bo? ! gr\p   
practice 7& any su* facility7 us+ ! mo/ 
rec5t available #c ye>s ( p]-b5efici>y  
exp5ditures = p>ts ,a & ,b s]vices =    
,m$ic>e fee-=-s]vice b5efici>ies = items
 & s]vices furni%$ by su* gr\p practice 
or skill$ nurs+ facility "u ! ,program4 
,su* b5*m>k %all be adju/$ = b5efici>y  
*>act]i/ics & su* o!r factors z !       
,secret>y det]m9es appropriate4 ,su*    
b5*m>k %all be reset at ! />t ( ea* ye>4
  7#b7 ,paym5ts = %>$ sav+s ,if a       
qualifi$ gr\p practice 7& any qualifi$  
skill$ nurs+ facility p>ticipat+ 9 !    
,program t has an agreem5t ) ! gr\p     
practice = ! furni%+ ( items & s]vices  
id5tifi$ "u subsection 7b77#c7 to       
resid5ts ( ! facility7 meets !          
requirem5ts "u p>agraph 7#a71 !         

,secret>y %all-- 7,a7 pay to su*        
qualifi$ gr\p practice an am\nt equal to
 #cg4e p]c5t ( ! diff]5ce betwe5 su*    
e/imat$ av]age p] capita ,m$ic>e        
exp5ditures 9 a ye>1 adju/$ = b5efici>y 
*>act]i/ics1 = items & s]vices furni%$  
"u ! ,program by ! gr\p practice 7& any 
su* facility7 & su* b5*m>k = ! qualifi$ 
gr\p practice 7& any su* facility72 &   
7,b7 9 ! case ( ea* su* facility-- 7i7  
if ! qualifi$ skill$ nurs+ facility has 
at lea/ a ?ree-/> rat+ "u ! ,five ,/>   
,quality ,rat+ ,sy/em 7or a successor   
sy/em71 pay to ! facility an am\nt t    
be>s ! same ratio to #ab4e p]c5t ( !    
e/imat$ am\nt ( su* diff]5ce z ! am\nt (
 exp5ditures "u ! ,program = su* items &
 s]vices furni%$ ) respect to           
individuals at su* facility by su*      
qualifi$ gr\p practice dur+ su* ye> be>s
 to ! total am\nt ( exp5ditures "u !    
,program = su* items & s]vices furni%$ )
 respect to all individuals by su*      
qualifi$ gr\p practice dur+ su* ye>2 &  
7ii7 9 ! case ( a qualifi$ skill$ nurs+ 

facility t is n describ$ 9 clause 7i71  
reta9 9 ! ,f$]al ,hospital ,insurance   
,tru/ ,fund "u section #ahag ! am\nt t !
 facility w\ld h be5 paid pursuant to   
clause 7i7 if ! facility 7 describ$ 9   
su* clause until su* "t z ! facility has
 at lea/ a ?ree-/> rat+ "u ! ,five ,/>  
,quality ,rat+ ,sy/em 7or a successor   
sy/em71 at :i* po9t ! ,secret>y %all pay
 su* am\nt to ! facility4  7#c7 ,advanc$
 alt]native paym5t models ,p>agraph 7#b7
 %all n apply to items & s]vices furni%$
 to an individual entitl$ to b5efits "u 
"p ,a & enroll$ "u ,"p ,b = :om %>$     
sav+s w\ld o!rwise be attribut$ ?r\gh an
 advanc$ alt]native paym5t model z      
au?oriz$ "u section #aaae;,a or section 
#ahii4  7e7 ,evaluation  7#a7 ,9 g5]al  
,) respect to a qualifi$ gr\p practice &
 a qualifi$ skill$ nurs+ facility1 n    
lat] ?an #f mon?s aft] su* gr\p practice
 beg9s furni%+ items & s]vices "u !     
,program 7or1 9 ! case ( a qualifi$     
skill$ nurs+ facility1 n less ?an #f    
mon?s aft] a qualifi$ gr\p practice fir/

 furni%es su* items & s]vices at su*    
facility71 & n less ?an once e #b ye>s  
!reaft]1 ! ,secret>y %all evaluate su*  
qualifi$ gr\p practice & su* qualifi$   
facility us+ in=mation receiv$ "u       
p>agraph 7#b7 on su* crit]ia z det]m9$  
appropriate by ! ,secret>y4  7#b7       
,report+ ( p]=mance & quality           
improvem5ts ,9 a "t & mann] specifi$ by 
! ,secret>y1 a qualifi$ gr\p practice & 
a qualifi$ skill$ nurs+ facility %all   
submit to ! ,secret>y a report conta9+ !
 foll[+ in=mation ) respect to items &  
s]vices furni%$ "u ! ,program dur+ a    
report+ p]iod 7z specifi$ by !          
,secret>y73 7,a7 ,! items & s]vices mo/ 
frequ5tly furni%$ "u ! ,program 9 su*   
p]iod4  7,b7 ,! numb] ( individuals )   
respect to :om su* gr\p practice furni%$
 su* items & s]vices 9 su* p]iod 7or1 9 
! case ( a qualifi$ skill$ nurs+        
facility1 ! numb] ( individuals )       
respect to :om su* a gr\p practice      
furni%$ su* items & s]vices at su*      
facility 9 su* p]iod74  7,c7 ,! numb] ( 

hospitalizations prev5t$ "u ! ,program 9
 su* p]iod4  7,d7 ,! numb] ( su*        
individuals :o 7 admitt$ to a hospital  
or treat$ 9 ! em]g5cy dep>tm5t ( a      
hospital )9 #bd h\rs ( be+ furni%$ su*  
items & s]vices4  7,e7 ,o!r in=mation   
det]m9$ appropriate by ! ,secret>y4     
7#c7 ,loss ( qualifi$ c]tification  7,a7
 ,9 g5]al ,n lat] ?an #c mon?s aft] a   
det]m9ation describ$ 9 ?is s5t5ce is    
made1 ! ,secret>y may revoke !          
c]tification ( a qualifi$ skill$ nurs+  
facility or a qualifi$ gr\p practice    
made "u subsection 7c7 if-- 7i7 ! ,*ief 
,actu>y ( ! ,c5t]s = ,m$ic>e  ,m$icaid  
,s]vices det]m9es t ! p>ticipation ( su*
 skill$ nurs+ facility or su* gr\p      
practice 9 ! ,program dur+ a ye> result$
 9 total exp5ditures "u ?is title = su* 
p]iod be+ great] ?an total exp5ditures  
"u su* title w\ld h be5 dur+ su* p]iod  
)\t su* p>ticipation2 or  7ii7 a        
facility is select$ = ! ,special ,focus 
,facility program or1 if ! facility is a
 c&idate = ! ,special ,focus ,facility  

program1 ! ,secret>y det]m9es t !       
p>ticipation ( su* facility 9 ! ,program
 %\ld be t]m9at$4  7,b7 ,exclusion f    
c]tification  7i7 ,9 g5]al ,9 ! case t !
 ,secret>y revokes ! c]tification ( a   
qualifi$ skill$ nurs+ facility or a     
qualifi$ gr\p practice "u subp>agraph   
7,a71 su* skill$ nurs+ facility or su*  
gr\p practice %all be ineligible =      
c]tification z a qualifi$ skill$ nurs+  
facility or a qualifi$ gr\p practice 7z 
applicable7 "u subsection 7c7 = !       
applicable p]iod 7z def9$ "u clause     
7ii774  7ii7 ,applicable p]iod def9$ ,9 
?is subp>agraph1 ! t]m applicable p]iod 
means-- 7,i7 if ! revocation ( a        
facility or gr\p practice "u subp>agraph
 7,a7 is due to ! application ( clause  
7i7 ( su* subp>agraph1 a #a-ye> p]iod   
beg9n+ on ! date ( su* revocation2 &    
7,,ii7 9 ! revocation ( a facility "u   
subp>agraph 7,a7 is due to ! application
 ( clause 7ii7 ( su* subp>agraph1 !     
p]iod beg9n+ on ! date ( su* revocation 
& end+ on ! date on :i* ! facility      

graduates f ! ,special ,focus ,facility 
program 7or1 9 ! case ( a facility t is 
a c&idate = su* program1 ! date on :i* !
 facility is no long] su* a c&idate1 z  
det]m9$ by ! ,secret>y74  7f7           
,det]m9ation ( budget neutrality2       
t]m9ation ( program  7#a7 ,det]m9ation  
,n lat] ?an ,july #a1 #bjbg1 ! ,*ief    
,actu>y ( ! ,c5t]s = ,m$ic>e  ,m$icaid  
,s]vices %all det]m9e :e!r ! ,program   
has result$ 9 an increase 9 total       
exp5ditures "u ?is title ) respect to ! 
p]iod beg9n+ on ,janu>y #a1 #bjbb1 &    
end+ on ,decemb] #ca1 #bjbf1 comp>$ to  
:at su* exp5ditures w\ld h be5 dur+ su* 
p]iod _h ! ,program n be5 9 op]ation4   
7#b7 ,t]m9ation ,if ! ,*ief ,actu>y     
makes a det]m9ation "u p>agraph 7#a7 t !
 ,program has result$ 9 an increase 9   
total exp5ditures "u ?is title1 !       
,secret>y %all t]m9ate ! ,program z (   
,janu>y #a ( ! fir/ ye> beg9n+ aft] su* 
det]m9ation4  4