,,ii #aaith ,,congress #b;d ,session ,s4 #daah ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,march #ag1 #bjbf ,mr4 ,warner introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to ensure the integrity of hospice care furnished under the ,medicare program1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,hospice ,care ,accountability1 ,reform1 and ,enforcement ,act of #bjbf or the ,hospice ,,care ,act of #bjbf4 #b4 ,ensuring the integrity of hospice care furnished under the ,medicare program 7a7 ,mandatory temporary moratorium on enrollment 7#a7 ,in general ,section #ahff7;j7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7j77 is amended by adding at the end the following new paragraph3 7#aj7 ,mandatory temporary moratorium on enrollment of hospice programs 7,a7 ,in general ,except as provided in subparagraphs 7,b7 and 7,c71 the ,secretary shall impose a nationwide temporary moratorium on the enrollment of new hospice programs under this title for the #e-year period beginning on the date of the enactment of this paragraph4 7,b7 ,exemption for certain hospices 7i7 ,in general ,the ,secretary may exempt a hospice program seeking to enroll under this title from the moratorium described in subparagraph 7,a7 if the ,secretary determines that such program will furnish hospice care to individuals entitled to benefits under part ,a in an area with insufficient access to such care 7as specified by the ,secretary1 taking into account the considerations described in clause 7ii774 7ii7 ,considerations described ,for purposes of clause 7i71 the considerations described in this clause are1 with respect to a hospice program seeking to enroll under this title1 the following3 7,i7 ,the specific geographic area that such program intends to serve4 7,,ii7 ,the current availability of hospice care in such area4 7,,iii7 ,any evidence of unmet need for hospice care in such area 7such as wait times for such care1 the extent to which such area 7or a population in such area7 is considered underserved1 and evidence that existing hospice programs are provided a substandard quality of care in such area74 7,,iv7 ,the program's plan to address any identified gaps in the provision of hospice care in such area4 7,c7 ,authority to lift moratorium ,the ,secretary may lift the moratorium imposed under subparagraph 7,a7 within a ,state 7or geographic region of a ,state7 specified by the ,secretary in the same manner as the ,secretary may lift a temporary moratorium 7as described in paragraph 7#g77 under section #dbd4egj7;d7 of title #db1 ,code of ,federal ,regulations 7or a successor regulation74 7,d7 ,application of prepayment medical review during the temporary moratorium in certain circumstances 7i7 ,in general ,subject to clause 7ii71 the ,secretary shall apply prepayment medical review to hospice care consisting of routine home care furnished during the #e-year period beginning on the date of the enactment of this paragraph by an applicable hospice program to a covered individual4 7ii7 ,termination of application of prepayment medical review 7,i7 ,in general ,the ,secretary shall terminate the application of prepayment medical review under clause 7i7 with respect to hospice care furnished by an applicable hospice program to a covered individual if the ,secretary determines that1 during the period in which such care so furnished by such program was subject to such review1 such care was subject to a low rate of denial 7as specified by the ,secretary7 under such review4 7,,ii7 ,revocation of termination ,the ,secretary may revoke any termination of prepayment medical review under subclause 7,i7 if determined appropriate by the ,secretary4 7iii7 ,definitions ,for purposes of this subparagraph3 7,i7 ,applicable hospice program ,the term applicable hospice program means a hospice program with a history of claim submissions with respect to hospice care furnished under this title that is aberrant 7such as by demonstrating that such program is an outlier with respect to live discharges7 compared to such history of claim submissions of similarly situated hospice programs1 as determined by the ,secretary4 7,,ii7 ,covered individual ,the term covered individual means an individual receiving hospice care under this title during the second #ij-;day period described in section #ahab7;d77#a7 7or during any subsequent period7 applicable to such individual4 7,e7 ,revalidation of enrollment information 7i7 ,in general ,during the #f-month period beginning on the date of the enactment of this paragraph and notwithstanding any applicable revalidation cycle under section #dbd4eae of title #db1 ,code of ,federal ,regulations 7or a successor regulation71 the ,secretary shall revalidate the enrollment information of each hospice program enrolled under this title in accordance with the requirements applicable to revalidations of such information under such section4 7ii7 ,publication of ownership information ,not later than #a year after the date of the enactment of this paragraph1 the ,secretary shall publish on a public website of the ,centers for ,medicare ,medicaid ,services ownership interest and managing control information collected pursuant to revalidations described in clause 7i7 for each hospice program enrolled under this title4 7iii7 ,report ,not later than ,january #a1 #bjbh1 the ,secretary1 acting through the ,assistant ,secretary for ,planning and ,evaluation1 shall submit to ,congress a report on hospice ownership and control trends and the role of private equity in ownership and control of hospice programs4 ,such report shall include-- 7,i7 validation1 to the extent feasible1 of the ownership and control information reported on form ,,cms-#hee;,a 7or any successor form72 7,,ii7 an analysis of hospice cost report data by ownership type2 7,,iii7 recommendations on ways to improve the integrity of the ownership and control information reported by hospices during the enrollment process under this title2 and 7,,iv7 to the extent practicable1 recommendations on policies to promote health care competition4 7,f7 ,implementation ,the ,secretary shall implement this paragraph through program instruction or other forms of subregulatory guidance4 4 7#b7 ,authority to provide exemptions to temporary moratoria ,section #ahff7;j77#g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7j77#g77 is amended-- 7,a7 in subparagraph 7,a71 by adding at the end the following new sentence3 ,the ,secretary may exempt a provider of services or supplier that would otherwise be subject to a moratorium imposed under the preceding sentence from such moratorium if determined appropriate by the ,secretary42 and 7,b7 in subparagraph 7,c77iii7-- 7i7 in subclause 7,i71 by striking and at the end2 7ii7 in subclause 7,,ii71 by striking the period and inserting 2 and2 and 7iii7 by adding at the end the following new subclause3 7,,iii7 is not subject to an exemption described in such subparagraph4 4 7b7 ,extension of oversight of newly ,enrolled hospice programs 7#a7 ,in general ,section #ahff7;j77#c77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7j77#c77;,a77 is amended by inserting 7or1 in the case of a hospice program1 not more than #b years7 after #a year4 7#b7 ,mandatory application of enhanced oversight for certain hospice programs ,section #ahff7;j77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7j77#c77 is amended-- 7,a7 by redesignating subparagraph 7,b7 as subparagraph 7,c72 and 7,b7 by inserting after subparagraph 7,a7 the following new subparagraph3 7,b7 ,mandatory application to certain hospice programs ,the procedures established by the ,secretary under subparagraph 7,a7 shall provide that any hospice program enrolling under this title that would1 but for application of subparagraph 7,b7 or 7,c7 of paragraph 7#aj71 have been prohibited from so enrolling be subject to the enhanced oversight described in such subparagraph for a period of not less than #cj days4 4 7c7 ,increase in survey frequency for certain hospice programs ,section #ahbb7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#f7;a77 is amended-- 7#a7 in paragraph 7#a7-- 7,a7 by inserting 1 with respect to such a survey conducted with respect to a hospice program that is not included on the list established under paragraph 7#e71 after local survey agency1 or2 and 7,b7 by inserting 7or1 in the case of a hospice program that is included on the list established under paragraph 7#e71 not less frequently than once every #ah months7 after #cf months2 7#b7 by redesignating paragraph 7#e7 as paragraph 7#f72 7#c7 by inserting after paragraph 7#d7 the following new paragraph3 7#e7 ,hospice programs subject to increased survey frequency 7,a7 ,in general ,the ,secretary shall establish a list of hospice programs subject to increased survey frequency under paragraph 7#a7 in accordance with the provisions of this paragraph4 7,b7 ,inclusion on list 7i7 ,in general ,the ,secretary shall include a hospice program on the list established under subparagraph 7,a7 if such program is not participating in the special focus program under subsection 7b7 and such hospice program meets either of the following criteria3 7,i7 ,the program first submitted a claim for an item or service under this title during the #e-year period ending on the date of the enactment of this paragraph4 7,,ii7 ,the program first submits a claim for an item or service under this title on or after such date of enactment4 7ii7 ,discretionary inclusion ,the ,secretary may include a hospice program on the list established under subparagraph 7,a7-- 7,i7 if claims data submitted by such program indicates that such program is not providing the full scope of hospice care services payable under this title2 7,,ii7 if the ,secretary determines that such program is an outlier with respect to live discharges2 or 7,,iii7 for any other reason determined appropriate by the ,secretary4 7,c7 ,removal from list ,the ,secretary shall remove a hospice program included in the list established under subparagraph 7,a7-- 7i7 if-- 7,i7 such program has been subject to #b surveys under this subsection while included on such list2 and 7,,ii7 neither such survey resulted in such program being cited for a deficiency for failure to comply with a condition of participation relating to quality of care2 or 7ii7 if such program is placed in the special focus program established under subsection 7b74 2 and 7#d7 in paragraph 7#f71 as so redesignated1 by striking each fiscal year 7beginning with fiscal year #bjbb7 and inserting each of fiscal years #bjbb through #bjbf1 and of #ae1jjj1jjj for fiscal year #bjbg and for each subsequent fiscal year14 7d7 ,prohibition on payment for failure ,to meet quality data reporting requirements ,section #ahad7;i77#e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7i77#e77 is amended-- 7#a7 in subparagraph 7,a7-- 7,a7 in the header1 by striking ,reduction in update for2 7,b7 in clause 7i7-- 7i7 in the header1 by striking ,in general and inserting ,fiscal years #bjad through #bjbg2 7ii7 by inserting through fiscal year #bjbg after each subsequent fiscal year2 and 7iii7 by adding at the end the following new sentence3 ,the application of the preceding sentence may result in the market basket percentage increase under paragraph 7#a77;,c77ii77,,vii7 or paragraph 7#a77;,c77iii71 as applicable1 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 year42 and 7,c7 by amending clause 7ii7 to read as follows3 7ii7 ,subsequent fiscal years ,for purposes of fiscal year #bjbh and each subsequent fiscal year1 no payment may be made under this title to a hospice program that does not submit data to the ,secretary in accordance with subparagraph 7,c7 with respect to such fiscal year4 2 and 7#b7 in subparagraph 7,b71 by striking subparagraph 7,a7 and inserting subparagraph 7,a77i74 7e7 ,ensuring independence of physician certifications of terminal illness ,section #ahad7;a77#g77;,a77i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7a77#g77;,a77i77 is amended-- 7#a7 in subclause 7,i71 by inserting or1 with respect to certifications under this clause occurring on or after ,october #a1 #bjbg1 in the case such individual fails to designate such an attending physician 7or in the case such attending physician is employed by the hospice program at which such individual will receive such care or otherwise has a significant ownership interest in1 or a significant financial relationship with1 such program 7as determined by the ,secretary771 by a physician1 physician assistant1 or nurse practitioner that does not have such a significant ownership interest in1 or such a significant financial relationship with1 such program 7as determined by the ,secretary7 before 1 and2 and 7#b7 in the matter following subclause 7,,ii71 by striking physician's and inserting physician's1 physician assistant's1 nurse practitioner's14 7f7 ,allowing additional providers ,to certify terminal illness 7#a7 ,in general ,section #ahad7;a77#g77;,a77i77,i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7a77#g77;,a77i77,i77 is amended by striking 7which for purposes of this subparagraph does not include a nurse practitioner or a physician assistant74 7#b7 ,effective date ,the amendment made by paragraph 7#a7 shall apply with respect to certifications of terminal illnesses made on or after ,october #a1 #bjbg4 7g7 ,allowable use of supporting material in medical review of hospice care ,section #ahad7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7a77 is amended by adding at the end the following new sentence3 ,for purposes of conducting medical review of hospice care furnished to an individual1 in addition to using documentation in the medical record of such individual's attending physician 7as defined in section #ahfa7;dd77 or of the physician1 physician assistant1 or nurse practitioner otherwise making the certification described in paragraph 7#g77;,a77i77,i7 with respect to such individual1 the ,secretary may use documentation in the medical record of the hospice program furnishing such care as supporting material1 as determined appropriate by the ,secretary44 7h7 ,prohibition on certain changes in majority ownership ,with respect to any change in the majority ownership of a hospice program occurring during the #e-year period beginning on the date of the enactment of this ,act1 the ,secretary of ,health and ,human ,services shall apply section #dbd4eej7;b7 of title #db1 ,code of ,federal ,regulations 7or a successor regulation7 as if the references to #cf months in paragraph 7#a7 of such section were references to #fj months4 7i7 ,advanced notice of changes in ownership or control ,section #ahbb of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#f7 is amended by adding at the end the following new subsection3 7d7 ,advanced notice of changes in ownership or control 7#a7 ,in general ,beginning ,january #a1 #bjbh1 in the case a change occurs in-- 7,a7 the persons with an ownership or control interest 7as defined in section #aabd7;a77#c77 in the hospice program2 7,b7 the persons who are officers1 directors1 agents1 or managing employees 7as defined in section #aabf7;b77 of the hospice program2 7,c7 the corporation1 association1 or other company responsible for the management of the hospice program2 or 7,d7 the individual who is the administrator of the hospice program1 or the individual who is the medical director of the hospice program2 such program shall provide notice at the time of the change 7or1 in the case such change is with respect to a person described in subparagraph 7,a71 at least #ij days before the effective date of the change7 to the ,secretary1 the appropriate ,state or local survey agency1 or appropriate approved accreditation agency of the change and of the identity of each new person1 company1 or individual described in the respective subparagraph4 7#b7 ,enforcement 7,a7 ,in general ,in the case that the ,secretary determines that a hospice program has violated paragraph 7#a71 the ,secretary may-- 7i7 impose a civil monetary penalty in an amount not to exceed #a1jjj1jjj per violation2 and 7ii7 if determined appropriate by the ,secretary1 terminate such program's enrollment under this title4 7,b7 ,procedures ,the provisions of section #aabh;,a 7other than subsections 7a7 and 7b7 of such section7 shall apply to a civil monetary penalty imposed under subparagraph 7,a7 in the same manner as such provisions apply to a penalty or proceeding under such section4 4 7j7 ,required provision of addendum of noncovered services ,section #ahab7;d77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;d7d77#a77 is amended by adding at the end the following new sentence3 ,with respect to such an election made on or after ,october #a1 #bjbg1 in the case such program determines that there are items and services being furnished to such individual that are not related to the treatment of the individual's condition with respect to which a diagnosis of terminal illness has been made1 such election shall include an addendum that specifies such items and services and includes such additional information as may be specified by the ,secretary4 ,such program shall provide an updated addendum described in the preceding sentence to such individual if1 while such election is in effect with respect to such individual1 such program makes any alteration to the addendum provided to such individual at the time of such election44 7k7 ,medical review of hospice outliers and care unrelated to terminal condition 7#a7 ,in general 7,a7 ,medical review ,section #ahad7;a77#g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7a77#g77 is amended-- 7i7 in subparagraph 7,d71 by striking and at the end2 7ii7 in subparagraph 7,e71 by inserting and before the date of the enactment of subparagraph 7,f71 after subparagraph12 and 7iii7 by adding at the end the following new subparagraph3 7,f7 beginning on the date that is #e years after the date of the enactment of this subparagraph1 in the case of hospice care provided an individual for more than #ij days by a hospice program with aberrant billing patterns 7as determined by the ,secretary71 the hospice care provided to such individual is subject to prepayment medical review 7in accordance with procedures established by the ,secretary72 and 4 7,b7 ,technical expert panel 7i7 ,in general ,the ,secretary of ,health and ,human ,services shall establish a technical expert panel for purposes of establishing standards for identifying a hospice program with a history of aberrant billing patterns under section #ahad7;a77#g77;,f7 of the ,social ,security ,act1 as added by subparagraph 7,a74 ,in making recommendations with respect to such standards1 such panel shall take into account the results of prepayment medical reviews conducted under section #ahff7;j77#aj77;,d7 of such ,act1 as added by subsection 7a74 7ii7 ,,faca waiver ,the provisions of chapter #aj of title #e1 ,united ,states ,code1 shall not apply to the panel established under clause 7i74 7#b7 ,prepayment medical review requirement ,section #ahab7;d77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;d7d77#b77 is amended by adding at the end the following new subparagraph3 7,e7 ,notwithstanding any other provision of this title1 in the case of items and services 7other than items and services described in the matter following clause 7ii77,,ii7 of subparagraph 7,a77 furnished on or after ,october #a1 #bjbg1 to an individual with an election in effect under paragraph 7#a7 by a provider of services or supplier1 if such provider of services or supplier indicates that such items and services are unrelated to the individual's condition with respect to which a diagnosis of terminal illness has been made1 no payment may be made under this title for such items and services before the ,secretary has conducted a medical review of such items and services to determine whether such items and services are unrelated to such condition4 ,such review shall include a review of any addendum described in paragraph 7#a7 included in such election4 4 7#c7 ,funding ,the ,secretary of ,health and ,human ,services shall provide for the transfer1 from the ,federal ,hospital ,insurance ,trust ,fund established under section #ahag of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i7 to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account1 of #bj1jjj1jjj for fiscal year #bjbg1 to remain available until expended1 for purposes of carrying out the amendments made by this subsection4 7l7 ,provision of explanation of benefits upon hospice election 7#a7 ,in general ,section #ahjf of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;b-#g7 is amended by adding at the end the following new subsection3 7d7 ,provision of explanation of benefits upon hospice election ,the ,secretary shall furnish to each individual who makes an election described in section #ahab7;d77#a71 not later than #ae days after such individual makes such election1 a notice that-- 7#a7 specifies-- 7,a7 the effective date of such election2 7,b7 the hospice program that will be furnishing hospice care to such individual2 7,c7 the telephone number and address of such program2 7,d7 the physician1 physician assistant1 or nurse practitioner who made the certification described in section #ahad7;a77#g77;,a77i77,i7 with respect to such individual2 7,e7 the toll-free telephone number of the medicare administrative contractor responsible for processing claims for such care2 7#b7 informs such individual of the waiver of rights described in section #ahab7;d77#b77;,a72 7#c7 includes a statement which indicates that1 because errors do occur and because ,medicare waste1 fraud1 and abuse is a significant problem1 such individual should carefully check the individual's hospice election information and if such individual suspects ,medicare waste1 fraud1 or abuse with respect to the provision of such care1 the individual should contact the toll-free phone number #a-hjj-,,medicare and a toll-free phone number maintained by the ,inspector ,general of the ,department of ,health and ,human ,services for the receipt of complaints and information about waste1 fraud1 and abuse in the provision or billing of services under this title2 and 7#d7 includes any other information determined appropriate by the ,secretary4 4 7#b7 ,funding ,the ,secretary of ,health and ,human ,services shall provide for the transfer from the ,federal ,hospital ,insurance ,trust ,fund established under section #ahag of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i7 to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account of #aj1jjj1jjj for fiscal year #bjbg1 to remain available until expended1 for purposes of carrying out the amendment made by paragraph 7#a74 7#c7 ,effective date ,the amendment made by paragraph 7#a7 shall apply to individuals making elections described in section #ahab7;d77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;d7d77#a77 on or after the date that is #a year after the date of the enactment of this ,act4 7m7 ,medical review of hospice care contractor requirements 7#a7 ,in general ,the ,secretary of ,health and ,human ,services 7in this subsection referred to as the ,secretary7 shall require any entity performing medical review under contract with the ,secretary of hospice care furnished under part ,a of title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;c et seq47 to1 with respect to such reviews performed on or after ,january #a1 #bjbh1 utilize only individuals who have received specialized instruction on the philosophy behind hospice care and medical prognostication 7as specified by the ,secretary7 in performing such reviews4 ,in so specifying such instruction and in updating such instruction1 the ,secretary shall consult with hospice programs as to the content of such instruction4 7#b7 ,publication ,the ,secretary shall make any instruction specified for purposes of paragraph 7#a7 publicly available on the website of the ,centers for ,medicare ,medicaid ,services4 7#c7 ,report ,not later than ,october #a1 #bjbh1 the ,secretary shall submit to ,congress a report on activities relating to the medical review of hospice care furnished under part ,a of title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;c et seq474 ,such report shall include-- 7,a7 with respect to the medical review of hospice care performed during the period beginning on ,january #a1 #bjbj1 and ending on ,december #ca1 #bjbe1 the accuracy rates of such reviews when performed by-- 7i7 medicare administrative contractors2 7ii7 recovery audit contractors2 7iii7 supplemental medical review contractors2 and 7iv7 uniform program integrity contractors2 7,b7 the total number of hospice claims submitted during the period described in subparagraph 7,a7 subject to medical review2 7,c7 the percentage of such claims that were denied and appealed and the percentage of such claims so appealed that were overturned on appeal1 broken down by the type of contractor conducting review of such claims and by each level of appeal2 7,d7 a list of medical review projects relating to hospice care undertaken by contractors described in subparagraph 7,a72 and 7,e7 actions the ,secretary will take to reduce the audit burden on hospice programs with claims selected for medical review under multiple projects described in subparagraph 7,d7 and to minimize the number of denials of claims for hospice care that are overturned on appeal4 7n7 ,requiring face-to-,face encounters before recertifications of terminal illness ,section #ahad7;a77#g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7a77#g77 is amended-- 7#a7 in subparagraph 7,d7-- 7,a7 in the matter preceding clause 7i71 by inserting 1 and before ,october #a1 #bjbg after #bjaa2 and 7,b7 by striking and at the end2 and 7#b7 by adding at the end the following new subparagraph3 7,f7 on and after ,october #a1 #bjbg1 not more than #cj days before each recertification described in subparagraph 7,a77ii7 is made with respect to an individual1 a hospice physician1 hospice nurse practitioner1 or hospice physician assistant has a face-to-face encounter 7which may1 with respect to any such recertification made for a #fj-;day period described in such subparagraph1 be conducted via telehealth1 but only if a registered nurse1 licensed practical nurse1 or home health aide employed by the hospice program furnishing hospice care to such individual is physically present with such individual during such encounter7 with such individual to gather clinical findings to determine such individual's continued eligibility for hospice care2 and 4 7o7 ,ensuring medical director and physician availability 7#a7 ,in general ,section #ahfa7;dd7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7dd77 is amended-- 7,a7 in paragraph 7#b7-- 7i7 in subparagraph 7,f71 by striking and at the end2 7ii7 by redesignating subparagraph 7,g7 as subparagraph 7,i72 and 7iii7 by inserting after subparagraph 7,f7 the following new subparagraphs3 7,g7 has a medical director responsible for the medical component of hospice care provided by such program who-- 7i7 is a doctor of medicine or osteopathy licensed to practice in the ,state in which such program is located2 and 7ii7 subject to paragraph 7#f71 is not the medical director of more than #a other hospice program2 7,h7 ensures that the medical director described in subparagraph 7,g7 or a physician member of the group described in subparagraph 7,b7 is available for immediate consultation 7which may be through telehealth7 when hospice care is provided in an individual's home2 and 2 and 7,b7 by adding at the end the following new paragraph3 7#f7 ,the ,secretary may waive the requirement described in paragraph 7#b77;,g77ii7 with respect to the medical director of a hospice program if determined appropriate by the ,secretary on a case-by-case basis4 ,in determining whether to grant a waiver under the preceding sentence1 the ,secretary shall take into consideration-- 7,a7 the average daily census for each hospice program with respect to which such director is medical director2 7,b7 the geographic areas served by such programs2 and 7,c7 any other information determined appropriate by the ,secretary4 4 7#b7 ,effective date ,the amendments made by paragraph 7#a7 shall apply beginning ,january #a1 #bjbi4 7p7 ,report on hospice accrediting organizations ,not later than #b years after the date of the enactment of this ,act1 the ,comptroller ,general of the ,united ,states shall submit to ,congress a report on the ,secretary of ,health and ,human ,services' 7in this subsection referred to as the ,secretary7 oversight of hospice program accrediting organizations4 ,such report shall include the following3 7#a7 ,an analysis of deficiencies relating to quality of care found pursuant to surveys conducted under section #ahbb7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#f7;a77 following complaints when such surveys were of hospice programs accredited by such an organization and such surveys were conducted by such an organization compared to such deficiencies so found following such complaints when such surveys were of hospice programs certified by ,state or local survey agencies and such surveys were conducted by such agencies4 7#b7 ,a list of hospice programs determined by the ,secretary not to be in compliance with all requirements applicable to such programs1 along with a list of the accrediting organization of each such program4 7#c7 ,a list of hospice programs that have been deactivated1 terminated1 or investigated due to concerns relating to waste1 fraud1 or abuse1 along with a list of the accrediting organization of each such program4 7#d7 ,an analysis of any conflicts of interest of hospice program accrediting organizations4 7#e7 ,performance data for hospice program accrediting organizations4 #c4 ,payment reforms for hospice care furnished under the ,medicare program 7a7 ,adjusting payments for hospice care 7#a7 ,in general ,section #ahad7;i77#a77;,c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7i77#a77;,c77 is amended-- 7,a7 in clause 7iii7-- 7i7 by moving such clause #f ems to the left2 7ii7 by striking ,with respect to and inserting ,except as provided under clauses 7viii7 through 7x71 with respect to2 7iii7 by inserting in a setting 7as specified by the ,secretary for purposes of clause 7vii77 after hospice care furnished2 7iv7 by inserting for such setting after payment rates in effect2 and 7v7 by striking under this clause and inserting under this subparagraph2 7,b7 in clause 7iv71 by striking clause 7ii77,,vii7 or 7iii7 each place such phrase appears and inserting clause 7iii7 or 7iv7 of paragraph 7#b77;,d7 or clause 7ii77,,vii71 7iii71 7viii71 7ix71 or 7x7 in each such place2 and 7,c7 by adding at the end the following new clauses3 7vii7 ,prior to the beginning of a specified fiscal year 7as defined in clause 7xi771 the ,secretary shall specify percentages by which the payment rates for hospice care consisting of services other than routine home care 7and1 for specified years beginning on or after ,october #a1 #bjcd1 for hospice care consisting of routine home care and other services included in hospice care7 in effect for the preceding fiscal year shall be adjusted in such specified fiscal year to align such rates with the costs of such care4 ,in specifying such percentages-- 7,i7 the ,secretary shall take into account changes in the average cost of such care and such other factors as determined appropriate by the ,secretary2 and 7,,ii7 the ,secretary may specify different percentages for such care based on the setting 7as specified by the ,secretary7 in which such care is furnished4 7viii7 7,i7 ,with respect to routine home care furnished during fiscal year #bjcj1 the payment rates for such care shall be equal to the sum of-- 7aa7 a per diem amount 7which may include an a case mix adjustment to account for variations in cost among different units of service7 reflecting the cost of routine home care not consisting of direct patient care for nursing care1 physical therapy1 occupational therapy1 speech-language pathology services1 medical social services 7other than counseling services71 home health aide services1 and physician services 7other than such services that are considered administrative services72 and 7bb7 subject to such frequency limits as may be specified by the ,secretary1 a per visit amount 7which may vary depending on the type and duration of the visit1 as determined appropriate by the ,secretary7 reflecting the cost of routine home care consisting of direct patient care excluded from the per diem amount established under item 7aa7 7other than1 in the case of such care furnished at a skilled nursing facility or nursing facility 7as defined in section #aiai7;a771 the component of such rates attributable to home health aide services74 7,,ii7 ,with respect to routine home care furnished during fiscal year #bjca or a subsequent fiscal year1 the payment rates for such care shall be equal to the sum of-- 7aa7 the per diem amount attributable to hospice care described in subclause 7,i77aa7 in effect under this clause for the preceding fiscal year1 adjusted1 in the case of a specified fiscal year1 by the percentages specified pursuant to clause 7vii7 for such specified fiscal year1 increased by the market basket percentage increase 7as defined in section #ahhf7;b77#c77;,b77iii77 for the fiscal year 7reduced in accordance with clause 7iv772 and 7bb7 the per visit amount for hospice care described in subclause 7,i77bb7 in effect under this clause for the preceding fiscal year1 adjusted1 in the case of a specified fiscal year1 by the percentages specified pursuant to clause 7vii7 for such specified fiscal year1 increased by such market basket percentage increase for the fiscal year 7reduced in accordance with clause 7iv774 7,,iii7 ,for purposes of this clause1 the term visit means1 with respect to an individual receiving hospice care from a hospice program1 in-person contact with such individual by staff of such program 7or by others under arrangements with such program71 not including any such contact conducted via telehealth or any other form of telecommunications technology4 7ix7 7,i7 ,with respect to routine home care consisting of specified hospice care 7as defined in subclause 7,,ii77 furnished by1 or under arrangements made by1 a hospice program during the period beginning on ,october #a1 #bjbg1 and ending on ,september #cj1 #bjcb1 in lieu of the rates otherwise payable under this subparagraph for such routine home care1 the ,secretary shall pay to the hospice program furnishing such care an amount equal to #djj percent of the amount payable for routine home care furnished in fiscal year #bjbg1 increased by the market basket percentage increase 7as defined in section #ahhf7;b77#c77;,b77iii77 for the fiscal year 7reduced in accordance with clause 7iv771 or such other amount determined appropriate by the ,secretary 7which may vary based on the type of service furnished7 for each day during which such specified hospice care was furnished4 7,,ii7 ,for purposes of subclause 7,i71 the term specified hospice care means any of the following items and services3 7aa7 ,palliative chemotherapy or radiation furnished under the supervision of an oncologist and in accordance with accepted clinical guidelines4 7bb7 ,palliative radiation therapy furnished under the supervision of an oncologist and in accordance with accepted clinical guidelines4 7cc7 ,subject to such frequency limitations as the ,secretary may establish1 palliative blood transfusions furnished to an individual diagnosed with a blood cancer and furnished under the supervision of an oncologist and in accordance with accepted clinical guidelines4 7dd7 ,palliative dialysis furnished under the supervision of a nephrologist1 but only if-- 7,,aa7 the individual receiving such palliative dialysis was receiving dialysis treatments prior to making the election under section #ahab7;d72 and 7,,bb7 such individual has received fewer than #aj sessions of such palliative in-center or home hemodialysis or the equivalent for peritoneal dialysis or other modalities 7or1 in the case such individual has received #aj or more such sessions or the equivalent of such sessions1 such session or equivalent of such session is subject to prior authorization74 7x7 ,with respect to hospice care consisting of services other than routine home care furnished during #bjcj or a subsequent fiscal year1 the payment rates for such care shall be equal to the rates in effect for such care for the preceding fiscal year1 adjusted1 in the case of a specified fiscal year1 by the percentages specified pursuant to clause 7vii7 for such specified fiscal year1 increased by the market basket percentage increase 7as defined in section #ahhf7;b77#c77;,b77iii77 for the fiscal year 7reduced in accordance with clause 7iv774 7xi7 ,for purposes of this subparagraph1 the term specified fiscal year means fiscal years #bjcj1 #bjce1 and #bjdj4 7xii7 7,i7 ,the ,secretary shall1 with respect to cost reporting periods beginning during an applicable fiscal year 7as defined in subclause 7,,iii771 conduct an audit of a representative sample of cost reports submitted by hospice programs4 7,,ii7 ,the ,secretary shall1 for each applicable fiscal year1 convene a technical expert panel for purposes of reviewing the methodology and results of the audit conducted under subclause 7,i7 with respect to such applicable fiscal year4 7,,iii7 ,for purposes of this clause1 the term applicable fiscal year means fiscal years #bjbf1 #bjca1 and #bjcf4 7,,iv7 ,the provisions of chapter #aj of title #e1 ,united ,states ,code1 shall not apply to the panel established under subclause 7,,ii74 7,v7 ,the ,secretary shall provide for the transfer1 from the ,federal ,hospital ,insurance ,trust ,fund established under section #ahag to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account1 of #aj1jjj1jjj for each of fiscal years #bjbg1 #bjcb1 and #bjcg1 to remain available until expended1 for purposes of carrying out this clause4 4 7#b7 ,outlier payments ,section #ahad7;i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7i77 is amended-- 7,a7 by redesignating paragraph 7#g7 as paragraph 7#h72 and 7,b7 by inserting after paragraph 7#f7 the following new paragraph3 7#g7 7,a7 ,subject to subparagraph 7,b71 with respect to routine home care furnished during a fiscal year beginning on or after ,october #a1 #bjcb1 the ,secretary may1 if determined appropriate by the ,secretary1 provide an additional payment for types of such care 7such as specified hospice care 7as defined in paragraph 7#a77;,c77ix777 specified by the ,secretary to account for unusual variations in the type or amount of such routine home care4 7,b7 7i7 ,the total amount of additional payments estimated to be made under subparagraph 7,a7 for routine home care furnished during a fiscal year may not exceed #e percent of the total amount of payments estimated to be made for such care furnished during such fiscal year without application of this paragraph for such fiscal year4 7ii7 ,the total amount of additional payments estimated to be made under subparagraph 7,a7 for routine home care furnished during a fiscal year to an individual hospice program may not exceed #aj percent of the total amount of payments estimated to be made for such care furnished during such fiscal year by such program without application of this paragraph for such fiscal year4 7,c7 ,the ,secretary shall reduce any per diem rate applicable under paragraph 7#a7 to routine home care furnished during the first fiscal year for which payments are made under subparagraph 7,a7 by such proportion as will result1 not taking into account any additional payments made under subparagraph 7,a7 for such care furnished during such fiscal year1 in an aggregate reduction of #e percent in payment for such care furnished during such fiscal year4 4 7#c7 ,plan of care requirements 7,a7 ,in general ,section #ahad7;a77#g77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7a77#g77;,b77 is amended by inserting and1 with respect to the establishment of such plan1 in the case such plan includes the furnishing of specified hospice care 7as defined in subsection 7i77#a77;,c77x77,,ii771 by a nephrologist 7if such care is care described in item 7dd7 of such subsection7 or by an oncologist 7if such care is care described in any of items 7aa7 through 7cc7 of such subsection7 who does not have a significant ownership interest in1 or a significant financial relationship with1 such hospice program1 as determined by the ,secretary1 and1 with respect to the periodic review of such plan1 in the case such plan includes the furnishing of specified hospice care 7as defined in subsection 7i77#a77;,c77x77,,ii771 by the nephrologist supervising the furnishing of such care 7if such care is described in item 7dd7 of such subsection7 or by the oncologist supervising the furnishing of such care 7if such care is described in any of items 7aa7 through 7cc7 of such subsection7 after of the hospice program4 7,b7 ,effective date ,the amendment made by subparagraph 7,a7 shall apply with respect to written plans for providing hospice care developed or reviewed on or after ,october #a1 #bjbg4 7#d7 ,excluding home health aide services and homemaker from the definition of hospice care in certain circumstances 7,a7 ,in general ,section #ahfa7;dd77#a77;,d77i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7dd77#a77;,d77i77 is amended by inserting in the case such individual is not residing in a skilled nursing facility or a nursing facility1 before services of a4 7,b7 ,homemaker services ,section #ahfa7;dd77#a77;,d77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7dd77#a77;,d77ii77 is amended by inserting 7but only if such individual is not residing in a skilled nursing facility or a nursing facility 7as defined in section #aiai7;a77 or1 if such individual is residing in such a skilled nursing facility or nursing facility1 only if such services are provided on a volunteer basis in accordance with paragraph 7#b77;,e77 after homemaker services4 7,c7 ,effective date ,the amendments made by subparagraphs 7,a7 and 7,b7 shall apply to items and services furnished on or after ,october #a1 #bjbi4 7#e7 ,conforming adjustment to 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 in clause 7i71 by striking clause 7ii7 and inserting clauses 7ii7 through 7iv72 7,b7 in clause 7ii71 by inserting 1 and subject to clause 7iii71 after subparagraph 7,a72 7,c7 by striking clause 7iii7 and inserting the following new clause3 7iii7 ,for purposes of subparagraph 7,a71 in the case of a specified fiscal year 7as defined in paragraph 7#a77;,c77xi771 the cap amount for such year is the cap amount under this subparagraph for the preceding fiscal year1 adjusted by the estimated percentage change in the total amount of payment made under this part for hospice care attributable to application of the amendments made by section #c7;a77#a7 of the ,hospice ,care ,accountability1 ,reform1 and ,enforcement ,act of #bjbf for such specified fiscal year and then increased by the market basket percentage increase 7as defined in section #ahhf7;b77#c77;,b77iii77 for such specified fiscal year 7reduced in accordance with paragraph 7#a77;,c77iv774 2 and 7,d7 by adding at the end the following new clause3 7iv7 ,for purposes of subparagraph 7,a71 and subject to clause 7iii71 for a fiscal year beginning on or after ,october #a1 #bjce1 the cap amount for such year is the cap amount under this subparagraph for the preceding fiscal year1 increased by the market basket percentage increase 7as defined in section #ahhf7;b77#c77;,b77iii77 for such fiscal year 7reduced in accordance with paragraph 7#a77;,c77iv774 4 7b7 ,wage adjusting caps 7#a7 ,in general ,section #ahad7;i77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7i77#b771 as amended by subsection 7a71 is further amended-- 7,a7 in subparagraph 7,a7-- 7i7 by striking cap amount for the year 7computed under subparagraph 7,b77 and inserting wage-adjusted cap 7as defined in subparagraph 7,b77 for such program and year2 and 7ii7 by striking subparagraph 7,c7 and inserting subparagraph 7,e72 7,b7 by redesignating subparagraphs 7,b7 through 7,d7 as subparagraphs 7,d7 through 7,f71 respectively2 7,c7 by inserting after subparagraph 7,a7 the following new subparagraphs3 7,b7 ,for purposes of subparagraph 7,a71 the term wage-adjusted cap means1 with respect to a hospice program and a year1 the product of-- 7i7 the wage index ratio 7as computed under subparagraph 7,c77 for such program and year2 and 7ii7 the cap amount for such year 7as computed under subparagraph 7,d774 7,c7 ,for purposes of subparagraph 7,b71 the wage index ratio for a hospice program and a year is the ratio of-- 7i7 the aggregate payments to such program for such year under paragraph 7#a72 to 7ii7 the aggregate payments to such program for such year under such paragraph that would have been made had such payments not been subject to any wage adjustment4 2 7,d7 in subparagraph 7,d71 as so redesignated-- 7i7 by striking subparagraph 7,a7 each place it appears and inserting subparagraph 7,b7 in each such place2 and 7ii7 by adding at the end the following new clause3 7v7 ,notwithstanding the preceding provisions of this subparagraph1 for a fiscal year beginning on or after ,october #a1 #bjbf1 the cap amount otherwise determined under this subparagraph for such fiscal year shall be decreased by the same percentage reduction 7if any7 applied to the amount of payment made under this part for such fiscal year under an order issued pursuant to section #bea of the ,balanced ,budget and ,emergency ,deficit ,control ,act of #aihe4 ,any reduction to the cap amount for a fiscal year under the preceding sentence shall not be taken into account for purposes of determining the cap amount for any succeeding fiscal year4 2 and 7,e7 by adding at the end the following new subparagraph3 7,g7 ,not later than #a year after the date of the enactment of this subparagraph1 and annually thereafter1 the ,secretary shall submit to ,congress and make public on the website of the ,centers for ,medicare ,medicaid ,services a report on the calculation of hospice programs' cap amounts under this paragraph4 ,such report shall contain1 with respect to each of the #e most recent accounting years for which data is available and each hospice program receiving payments under this section for hospice care furnished during such year1 the following3 7i7 ,such program's cap amount determined under such section4 7ii7 ,the percentage of such program's cap amount paid to such program for such care4 7iii7 ,in the case payments to such program exceeded such cap1 any amount recouped by the ,secretary with respect to such program4 7iv7 ,the live discharge rate of such program4 4 7#b7 ,implementation ,notwithstanding any other provision of law1 the ,secretary of ,health and ,human ,services may implement the amendments made by paragraph 7#a7 by program instruction or otherwise4 7#c7 ,effective date ,the amendments made by subparagraphs 7,a7 through 7,c7 of paragraph 7#a7 shall apply with respect to payment for hospice care furnished during fiscal years beginning on or after ,october #a1 #bjbg4 7c7 ,modification of requirements relating to short-,term inpatient care 7#a7 ,in general ,section #ahfa7;dd7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7dd77 is amended-- 7,a7 in paragraph 7#a7-- 7i7 in subparagraph 7,g71 by striking consecutively over longer than five days and inserting for more than #e days during any #ij-;day election period 7or #fj-;day election period1 as applicable7 described in section #ahab7;d77#a72 and 7ii7 in the flush matter following subparagraph 7,i71 by adding at the end the following new sentence3 ,in the case of an individual who receives short-term inpatient care described in subparagraph 7,g7 consisting of respite care during an election period and the furnishing of such care is immediately preceded by a hospital stay 7which may include a stay for observation7 during which such individual made an election described in section #ahab7;d77#a7 for the first time during such individual's lifetime 7or if such care is immediately preceded by the furnishing of hospice care consisting of general inpatient care and such general inpatient care is immediately preceded by such a hospital stay71 the first continuous #ae days of such care shall not be taken into account for purposes of applying the limitation on the number of days during which such care may be furnished during an election period under such subparagraph1 but only if such individual does not have sufficient caregiver support to be discharged to the individual's home42 and 7,b7 in paragraph 7#b7-- 7i7 in subparagraph 7,a77iii7-- 7,i7 by striking provides assurances satisfactory to the ,secretary that and inserting ensures that the sum of2 and 7,,ii7 by striking #bj percent and inserting #aj percent 7or a higher percent 7not to exceed #bj percent7 specified by the ,secretary if determined necessary by the ,secretary to ensure sufficient access to such inpatient care72 and 7ii7 by adding at the end the following flush sentence3 ,for purposes of subparagraph 7,a77iii71 the ,secretary shall ensure that the limitation described in such subparagraph is applied1 to the extent practicable1 on a real-time basis4 4 7#b7 ,allowing respite care to be furnished in residential care facilities ,not later than ,october #a1 #bjbg1 the ,secretary of ,health and ,human ,services 7in this paragraph referred to as the ,secretary7 shall revise section #dah4ajh of title #db1 ,code of ,federal ,regulations 7or a successor regulation7 to allow short-term inpatient care consisting of respite care 7as described in section #ahfa7;dd77#a77;,g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7dd77#a77;,g777 to be furnished in residential care facilities 7as defined by the ,secretary7 that only provide care to individuals receiving hospice care 7as specified by the ,secretary7 and that meet such standards relating to health and safety as the ,secretary may specify 7which may be based on ,state licensure requirements applicable to such facilities74 7#c7 ,effective date ,the amendments made by paragraph 7#a7 shall apply to hospice care furnished on or after ,october #a1 #bjbg4 7d7 ,hospital discharge planning requirements 7#a7 ,in general ,section #ahfa7;ee77#b77;,d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7ee77#b77;,d77 is amended-- 7,a7 by inserting 1 home health services1 after including hospice care2 7,b7 by striking including the availability of home health services through individuals and entities and inserting the following3 including-- 7i7 in the case of individuals who are likely to need home health services1 the availability of such services through home health agencies 2 7,c7 by striking listed by the hospital as available and1 in the case of individuals who are likely to need post-hospital extended care services1 and inserting the following3 listed by the hospital as available2 7ii7 in the case of individuals who are likely to need post-hospital extended care services1 2 7,d7 by striking the period and inserting 2 and2 and 7,e7 by adding at the end the following new clause3 7iii7 in the case of individuals who are likely eligible for hospice care1 the availability of such care 7including the availability of respite care described in subsection 7dd77#a77;,g77 through hospice programs that participate in the program under this title and that serve the area in which the patient resides4 4 7#b7 ,effective date ,the amendments made by paragraph 7#a7 shall apply with respect to discharges occurring on or after ,october #a1 #bjbg4 7e7 ,payment for respite care furnished in the home 7#a7 ,in general ,section #ahfa7;dd77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7dd77#a77 is amended-- 7,a7 in subparagraph 7,h71 by striking and at the end2 7,b7 by redesignating subparagraph 7,i7 as subparagraph 7,j72 and 7,c7 by inserting after subparagraph 7,h7 the following new subparagraph3 7,i7 short-term home respite care furnished to an individual on or after ,october #a1 #bjbi1 that-- 7i7 is furnished in the place of residence used as such individual's home 7other than a skilled nursing facility1 a nursing facility 7as defined in section #aiai7;a771 an assisted living facility 7as defined by the ,secretary71 or another facility specified by the ,secretary72 7ii7 is furnished on an intermittent1 nonroutine1 and occasional basis2 7iii7 is furnished for not more than #abj hours during any #ij-;day period described in section #ahab7;d77#a7 7or1 in the case of any #fj-;day period described in such section1 for not more than #hj hours during such period72 and 7iv7 meets such other requirements as the ,secretary may specify4 4 7#b7 ,payment rates ,section #ahad7;i77#a77;,c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7i77#a77;,c771 as amended by subsection 7a71 is further amended-- 7,a7 in clause 7iii71 by striking through 7x7 and inserting through 7x7 and clause 7xiii72 and 7,b7 by adding at the end the following new clause3 7xiii7 ,with respect to short-term home respite care furnished to an individual during fiscal year #bjcj or a subsequent fiscal year1 the rates payable for such care shall be equal to the sum of the per diem rate established for routine home care for such fiscal year and an hourly rate established by the ,secretary1 except that in no case may such rate payable for such short-term home respite care furnished in a #bd-;hour period exceed the rate of payment for general inpatient care furnished during such a period4 4