,,ii  #aai? ,,congress  #b;d ,session   
,s4 #daah  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,m>* #ag1 #bjbf ,mr4   
,w>n] introduc$ ! foll[+ bill2 :i* 0    
read twice & ref]r$ to ! ,committee on  
,f9ance  ,a ,,bill  ,to am5d title      
,,xviii ( ! ,social ,security ,act to   
ensure ! integrity ( hospice c>e furni%$
 "u ! ,m$ic>e program1 & = o!r purposes4
  #a4 ,%ort title ,?is ,act may be cit$ 
z ! ,hospice ,c>e ,acc\ntability1 ,re=m1
 & ,en=cem5t ,act ( #bjbf or ! ,hospice 
,,c>e ,act ( #bjbf4  #b4 ,ensur+ !      
integrity ( hospice c>e furni%$ "u !    
,m$ic>e program  7a7 ,m&atory tempor>y  
moratorium on enrollm5t  7#a7 ,9 g5]al  
,section #ahff7;j7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #acie;cc7j77 is    
am5d$ by add+ at ! end ! foll[+ new     
p>agraph3  7#aj7 ,m&atory tempor>y      
moratorium on enrollm5t ( hospice       
programs  7,a7 ,9 g5]al ,except z       
provid$ 9 subp>agraphs 7,b7 & 7,c71 !   
,secret>y %all impose a nationwide      
tempor>y moratorium on ! enrollm5t ( new

 hospice programs "u ?is title = !      
#e-ye> p]iod beg9n+ on ! date ( !       
enactm5t ( ?is p>agraph4  7,b7          
,exemption = c]ta9 hospices  7i7 ,9     
g5]al ,! ,secret>y may exempt a hospice 
program seek+ to enroll "u ?is title f !
 moratorium describ$ 9 subp>agraph 7,a7 
if ! ,secret>y det]m9es t su* program w 
furni% hospice c>e to individuals       
entitl$ to b5efits "u "p ,a 9 an area ) 
insuffici5t access to su* c>e 7z        
specifi$ by ! ,secret>y1 tak+ into      
acc\nt ! consid]ations describ$ 9 clause
 7ii774  7ii7 ,consid]ations describ$ ,=
 purposes ( clause 7i71 ! consid]ations 
describ$ 9 ?is clause are1 ) respect to 
a hospice program seek+ to enroll "u ?is
 title1 ! foll[+3 7,i7 ,! specific      
geographic area t su* program int5ds to 
s]ve4  7,,ii7 ,! curr5t availability (  
hospice c>e 9 su* area4  7,,iii7 ,any   
evid5ce ( unmet ne$ = hospice c>e 9 su* 
area 7su* z wait times = su* c>e1 !     
ext5t to :i* su* area 7or a population 9
 su* area7 is consid]$ und]s]v$1 &      

evid5ce t exi/+ hospice programs are    
provid$ a sub/&>d quality ( c>e 9 su*   
area74  7,,iv7 ,! program's plan to     
address any id5tifi$ gaps 9 ! provision 
( hospice c>e 9 su* area4  7,c7         
,au?ority to lift moratorium ,!         
,secret>y may lift ! moratorium impos$  
"u subp>agraph 7,a7 )9 a ,/ate 7or      
geographic region ( a ,/ate7 specifi$ by
 ! ,secret>y 9 ! same mann] z !         
,secret>y may lift a tempor>y moratorium
 7z describ$ 9 p>agraph 7#g77 "u section
 #dbd4egj7;d7 ( title #db1 ,code (      
,f$]al ,regulations 7or a successor     
regulation74  7,d7 ,application (       
prepaym5t m$ical review dur+ ! tempor>y 
moratorium 9 c]ta9 circum/ances  7i7 ,9 
g5]al ,subject to clause 7ii71 !        
,secret>y %all apply prepaym5t m$ical   
review to hospice c>e consi/+ ( r\t9e   
home c>e furni%$ dur+ ! #e-ye> p]iod    
beg9n+ on ! date ( ! enactm5t ( ?is     
p>agraph by an applicable hospice       
program to a cov]$ individual4  7ii7    
,t]m9ation ( application ( prepaym5t    

m$ical review  7,i7 ,9 g5]al ,!         
,secret>y %all t]m9ate ! application (  
prepaym5t m$ical review "u clause 7i7 ) 
respect to hospice c>e furni%$ by an    
applicable hospice program to a cov]$   
individual if ! ,secret>y det]m9es t1   
dur+ ! p]iod 9 :i* su* c>e s furni%$ by 
su* program 0 subject to su* review1 su*
 c>e 0 subject to a l[ rate ( d5ial 7z  
specifi$ by ! ,secret>y7 "u su* review4 
7,,ii7 ,revocation ( t]m9ation ,!       
,secret>y may revoke any t]m9ation (    
prepaym5t m$ical review "u subclause    
7,i7 if det]m9$ appropriate by !        
,secret>y4  7iii7 ,def9itions ,=        
purposes ( ?is subp>agraph3  7,i7       
,applicable hospice program ,! t]m      
applicable hospice program means a      
hospice program ) a hi/ory ( claim      
submissions ) respect to hospice c>e    
furni%$ "u ?is title t is ab]rant 7su* z
 by demon/rat+ t su* program is an      
outli] ) respect to live dis*>ges7      
comp>$ to su* hi/ory ( claim submissions
 ( simil>ly situat$ hospice programs1 z 

det]m9$ by ! ,secret>y4  7,,ii7 ,cov]$  
individual ,! t]m cov]$ individual means
 an individual receiv+ hospice c>e "u   
?is title dur+ ! second #ij-;day p]iod  
describ$ 9 section #ahab7;d77#a7 7or    
dur+ any subsequ5t p]iod7 applicable to 
su* individual4  7,e7 ,revalidation (   
enrollm5t in=mation  7i7 ,9 g5]al ,dur+ 
! #f-mon? p]iod beg9n+ on ! date ( !    
enactm5t ( ?is p>agraph & not)/&+ any   
applicable revalidation cycle "u section
 #dbd4eae ( title #db1 ,code ( ,f$]al   
,regulations 7or a successor            
regulation71 ! ,secret>y %all revalidate
 ! enrollm5t in=mation ( ea* hospice    
program enroll$ "u ?is title 9          
accordance ) ! requirem5ts applicable to
 revalidations ( su* in=mation "u su*   
section4  7ii7 ,publication ( own]%ip   
in=mation ,n lat] ?an #a ye> aft] ! date
 ( ! enactm5t ( ?is p>agraph1 !         
,secret>y %all publi% on a public       
website ( ! ,c5t]s = ,m$ic>e  ,m$icaid  
,s]vices own]%ip int]e/ & manag+ control
 in=mation collect$ pursuant to         

revalidations describ$ 9 clause 7i7 =   
ea* hospice program enroll$ "u ?is      
title4  7iii7 ,report ,n lat] ?an       
,janu>y #a1 #bjbh1 ! ,secret>y1 act+    
?r\gh ! ,assi/ant ,secret>y = ,plann+ & 
,evaluation1 %all submit to ,congress a 
report on hospice own]%ip & control     
tr5ds & ! role ( private equity 9       
own]%ip & control ( hospice programs4   
,su* report %all include-- 7,i7         
validation1 to ! ext5t feasible1 ( !    
own]%ip & control in=mation report$ on  
=m ,,cms-#hee;,a 7or any successor =m72 
7,,ii7 an analysis ( hospice co/ report 
data by own]%ip type2  7,,iii7          
recomm5dations on ways to improve !     
integrity ( ! own]%ip & control         
in=mation report$ by hospices dur+ !    
enrollm5t process "u ?is title2 &       
7,,iv7 to ! ext5t practicable1          
recomm5dations on policies to promote   
heal? c>e competition4  7,f7            
,implem5tation ,! ,secret>y %all        
implem5t ?is p>agraph ?r\gh program     
in/ruction or o!r =ms ( subregulatory   

guidance4  4  7#b7 ,au?ority to provide 
exemptions to tempor>y moratoria        
,section #ahff7;j77#g7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acie;cc7j77#g77 is am5d$-- 7,a7 9      
subp>agraph 7,a71 by add+ at ! end !    
foll[+ new s5t5ce3 ,! ,secret>y may     
exempt a provid] ( s]vices or suppli] t 
w\ld o!rwise be subject to a moratorium 
impos$ "u ! prec$+ s5t5ce f su*         
moratorium if det]m9$ appropriate by !  
,secret>y42 &  7,b7 9 subp>agraph       
7,c77iii7-- 7i7 9 subclause 7,i71 by    
/rik+ & at ! end2  7ii7 9 subclause     
7,,ii71 by /rik+ ! p]iod & ins]t+ 2 &2 &
  7iii7 by add+ at ! end ! foll[+ new   
subclause3  7,,iii7 is n subject to an  
exemption describ$ 9 su* subp>agraph4  4
  7b7 ,ext5sion ( ov]sight ( newly      
,enroll$ hospice programs  7#a7 ,9 g5]al
 ,section #ahff7;j77#c77;,a7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          
#acie;cc7j77#c77;,a77 is am5d$ by ins]t+
 7or1 9 ! case ( a hospice program1 n m 
?an #b ye>s7 aft] #a ye>4  7#b7 ,m&atory

 application ( enhanc$ ov]sight = c]ta9 
hospice programs ,section #ahff7;j77#c7 
( ! ,social ,security ,act 7#db         
,u4,s4,c4 #acie;cc7j77#c77 is am5d$--   
7,a7 by r$esignat+ subp>agraph 7,b7 z   
subp>agraph 7,c72 &  7,b7 by ins]t+ aft]
 subp>agraph 7,a7 ! foll[+ new          
subp>agraph3  7,b7 ,m&atory application 
to c]ta9 hospice programs ,! proc$ures  
e/abli%$ by ! ,secret>y "u subp>agraph  
7,a7 %all provide t any hospice program 
enroll+ "u ?is title t w\ld1 b =        
application ( subp>agraph 7,b7 or 7,c7 (
 p>agraph 7#aj71 h be5 prohibit$ f s    
enroll+ be subject to ! enhanc$ ov]sight
 describ$ 9 su* subp>agraph = a p]iod ( 
n less ?an #cj days4  4  7c7 ,increase 9
 survey frequ5cy = c]ta9 hospice        
programs ,section #ahbb7;a7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#acie;i-#f7;a77 is am5d$-- 7#a7 9       
p>agraph 7#a7--  7,a7 by ins]t+ 1 )     
respect to su* a survey conduct$ )      
respect to a hospice program t is n     
includ$ on ! li/ e/abli%$ "u p>agraph   

7#e71 aft] local survey ag5cy1 or2 &    
7,b7 by ins]t+ 7or1 9 ! case ( a hospice
 program t is includ$ on ! li/ e/abli%$ 
"u p>agraph 7#e71 n less frequ5tly ?an  
once e #ah mon?s7 aft] #cf mon?s2  7#b7 
by r$esignat+ p>agraph 7#e7 z p>agraph  
7#f72  7#c7 by ins]t+ aft] p>agraph 7#d7
 ! foll[+ new p>agraph3  7#e7 ,hospice  
programs subject to increas$ survey     
frequ5cy  7,a7 ,9 g5]al ,! ,secret>y    
%all e/abli% a li/ ( hospice programs   
subject to increas$ survey frequ5cy "u  
p>agraph 7#a7 9 accordance ) !          
provisions ( ?is p>agraph4  7,b7        
,inclusion on li/  7i7 ,9 g5]al ,!      
,secret>y %all include a hospice program
 on ! li/ e/abli%$ "u subp>agraph 7,a7  
if su* program is n p>ticipat+ 9 !      
special focus program "u subsection 7b7 
& su* hospice program meets ei!r ( !    
foll[+ crit]ia3  7,i7 ,! program fir/   
submitt$ a claim = an item or s]vice "u 
?is title dur+ ! #e-ye> p]iod end+ on ! 
date ( ! enactm5t ( ?is p>agraph4       
7,,ii7 ,! program fir/ submits a claim =

 an item or s]vice "u ?is title on or   
aft] su* date ( enactm5t4  7ii7         
,discretion>y inclusion ,! ,secret>y may
 include a hospice program on ! li/     
e/abli%$ "u subp>agraph 7,a7-- 7,i7 if  
claims data submitt$ by su* program     
indicates t su* program is n provid+ !  
full scope ( hospice c>e s]vices payable
 "u ?is title2  7,,ii7 if ! ,secret>y   
det]m9es t su* program is an outli] )   
respect to live dis*>ges2 or  7,,iii7 = 
any o!r reason det]m9$ appropriate by ! 
,secret>y4  7,c7 ,removal f li/ ,!      
,secret>y %all remove a hospice program 
includ$ 9 ! li/ e/abli%$ "u subp>agraph 
7,a7-- 7i7 if--  7,i7 su* program has   
be5 subject to #b surveys "u ?is        
subsection :ile includ$ on su* li/2 &   
7,,ii7 nei!r su* survey result$ 9 su*   
program be+ cit$ = a defici5cy = failure
 to comply ) a condition ( p>ticipation 
relat+ to quality ( c>e2 or  7ii7 if su*
 program is plac$ 9 ! special focus     
program e/abli%$ "u subsection 7b74  2 &
  7#d7 9 p>agraph 7#f71 z s r$esignat$1 

by /rik+ ea* fiscal ye> 7beg9n+ ) fiscal
 ye> #bjbb7 & ins]t+ ea* ( fiscal ye>s  
#bjbb ?r\gh #bjbf1 & ( #ae1jjj1jjj =    
fiscal ye> #bjbg & = ea* subsequ5t      
fiscal ye>14  7d7 ,prohibition on paym5t
 = failure ,to meet quality data report+
 requirem5ts ,section #ahad7;i77#e7 ( ! 
,social ,security ,act 7#db ,u4,s4,c4   
#acie;f7i77#e77 is am5d$-- 7#a7 9       
subp>agraph 7,a7--  7,a7 9 ! head]1 by  
/rik+ ,r$uction 9 update =2  7,b7 9     
clause 7i7--  7i7 9 ! head]1 by /rik+ ,9
 g5]al & ins]t+ ,fiscal ye>s #bjad ?r\gh
 #bjbg2  7ii7 by ins]t+ ?r\gh fiscal ye>
 #bjbg aft] ea* subsequ5t fiscal ye>2 & 
7iii7 by add+ at ! end ! foll[+ new     
s5t5ce3 ,! application ( ! prec$+ s5t5ce
 may result 9 ! m>ket basket p]c5tage   
increase "u p>agraph                    
7#a77;,c77ii77,,vii7 or p>agraph        
7#a77;,c77iii71 z applicable1 be+ less  
?an #j4j = a fiscal ye>1 & may result 9 
paym5t rates "u ?is subsection = a      
fiscal ye> be+ less ?an su* paym5t rates
 = ! prec$+ fiscal ye>42 &  7,c7 by     

am5d+ clause 7ii7 to read z foll[s3     
7ii7 ,subsequ5t fiscal ye>s ,= purposes 
( fiscal ye> #bjbh & ea* subsequ5t      
fiscal ye>1 no paym5t may be made "u ?is
 title to a hospice program t does n    
submit data to ! ,secret>y 9 accordance 
) subp>agraph 7,c7 ) respect to su*     
fiscal ye>4  2 &  7#b7 9 subp>agraph    
7,b71 by /rik+ subp>agraph 7,a7 & ins]t+
 subp>agraph 7,a77i74  7e7 ,ensur+      
indep5d5ce ( physician c]tifications (  
t]m9al illness ,section                 
#ahad7;a77#g77;,a77i7 ( ! ,social       
,security ,act 7#db ,u4,s4,c4           
#acie;f7a77#g77;,a77i77 is am5d$-- 7#a7 
9 subclause 7,i71 by ins]t+ or1 )       
respect to c]tifications "u ?is clause  
occurr+ on or aft] ,octob] #a1 #bjbg1 9 
! case su* individual fails to designate
 su* an att5d+ physician 7or 9 ! case   
su* att5d+ physician is employ$ by !    
hospice program at :i* su* individual w 
receive su* c>e or o!rwise has a        
significant own]%ip int]e/ 91 or a      
significant f9ancial relation%ip )1 su* 

program 7z det]m9$ by ! ,secret>y771 by 
a physician1 physician assi/ant1 or     
nurse practition] t does n h su* a      
significant own]%ip int]e/ 91 or su* a  
significant f9ancial relation%ip )1 su* 
program 7z det]m9$ by ! ,secret>y7 be=e 
1 &2 &  7#b7 9 ! matt] foll[+ subclause 
7,,ii71 by /rik+ physician's & ins]t+   
physician's1 physician assi/ant's1 nurse
 practition]'s14  7f7 ,all[+ additional 
provid]s ,to c]tify t]m9al illness  7#a7
 ,9 g5]al ,section                      
#ahad7;a77#g77;,a77i77,i7 ( ! ,social   
,security ,act 7#db ,u4,s4,c4           
#acie;f7a77#g77;,a77i77,i77 is am5d$ by 
/rik+ 7:i* = purposes ( ?is subp>agraph 
does n include a nurse practition] or a 
physician assi/ant74  7#b7 ,effective   
date ,! am5dm5t made by p>agraph 7#a7   
%all apply ) respect to c]tifications ( 
t]m9al illnesses made on or aft] ,octob]
 #a1 #bjbg4  7g7 ,all[able use (        
support+ mat]ial 9 m$ical review (      
hospice c>e ,section #ahad7;a7 ( !      
,social ,security ,act 7#db ,u4,s4,c4   

#acie;f7a77 is am5d$ by add+ at ! end ! 
foll[+ new s5t5ce3 ,= purposes (        
conduct+ m$ical review ( hospice c>e    
furni%$ to an individual1 9 addition to 
us+ docum5tation 9 ! m$ical record ( su*
 individual's att5d+ physician 7z def9$ 
9 section #ahfa7;dd77 or ( ! physician1 
physician assi/ant1 or nurse practition]
 o!rwise mak+ ! c]tification describ$ 9 
p>agraph 7#g77;,a77i77,i7 ) respect to  
su* individual1 ! ,secret>y may use     
docum5tation 9 ! m$ical record ( !      
hospice program furni%+ su* c>e z       
support+ mat]ial1 z det]m9$ appropriate 
by ! ,secret>y44  7h7 ,prohibition on   
c]ta9 *anges 9 majority own]%ip ,)      
respect to any *ange 9 ! majority       
own]%ip ( a hospice program occurr+ dur+
 ! #e-ye> p]iod beg9n+ on ! date ( !    
enactm5t ( ?is ,act1 ! ,secret>y (      
,heal? & ,human ,s]vices %all apply     
section #dbd4eej7;b7 ( title #db1 ,code 
( ,f$]al ,regulations 7or a successor   
regulation7 z if ! ref]5ces to #cf mon?s
 9 p>agraph 7#a7 ( su* section 7        

ref]5ces to #fj mon?s4  7i7 ,advanc$    
notice ( *anges 9 own]%ip or control    
,section #ahbb ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #acie;i-#f7 is am5d$
 by add+ at ! end ! foll[+ new          
subsection3  7d7 ,advanc$ notice (      
*anges 9 own]%ip or control  7#a7 ,9    
g5]al ,beg9n+ ,janu>y #a1 #bjbh1 9 !    
case a *ange occurs 9-- 7,a7 ! p]sons ) 
an own]%ip or control int]e/ 7z def9$ 9 
section #aabd7;a77#c77 9 ! hospice      
program2  7,b7 ! p]sons :o are (fic]s1  
directors1 ag5ts1 or manag+ employees 7z
 def9$ 9 section #aabf7;b77 ( ! hospice 
program2  7,c7 ! corporation1           
association1 or o!r company responsible 
= ! managem5t ( ! hospice program2 or   
7,d7 ! individual :o is ! adm9i/rator ( 
! hospice program1 or ! individual :o is
 ! m$ical director ( ! hospice program2 
su* program %all provide notice at ! "t 
( ! *ange 7or1 9 ! case su* *ange is )  
respect to a p]son describ$ 9           
subp>agraph 7,a71 at lea/ #ij days be=e 
! effective date ( ! *ange7 to !        

,secret>y1 ! appropriate ,/ate or local 
survey ag5cy1 or appropriate approv$    
accr$itation ag5cy ( ! *ange & ( !      
id5tity ( ea* new p]son1 company1 or    
individual describ$ 9 ! respective      
subp>agraph4  7#b7 ,en=cem5t  7,a7 ,9   
g5]al ,9 ! case t ! ,secret>y det]m9es t
 a hospice program has violat$ p>agraph 
7#a71 ! ,secret>y may--  7i7 impose a   
civil monet>y p5alty 9 an am\nt n to    
exce$ #a1jjj1jjj p] violation2 &  7ii7  
if det]m9$ appropriate by ! ,secret>y1  
t]m9ate su* program's enrollm5t "u ?is  
title4  7,b7 ,proc$ures ,! provisions ( 
section #aabh;,a 7o!r ?an subsections   
7a7 & 7b7 ( su* section7 %all apply to a
 civil monet>y p5alty impos$ "u         
subp>agraph 7,a7 9 ! same mann] z su*   
provisions apply to a p5alty or proce$+ 
"u su* section4  4  7j7 ,requir$        
provision ( add5dum ( noncov]$ s]vices  
,section #ahab7;d77#a7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acie;d7d77#a77 is am5d$ by add+ at !   
end ! foll[+ new s5t5ce3 ,) respect to  

su* an election made on or aft] ,octob] 
#a1 #bjbg1 9 ! case su* program det]m9es
 t !re are items & s]vices be+ furni%$  
to su* individual t are n relat$ to !   
treatm5t ( ! individual's condition )   
respect to :i* a diagnosis ( t]m9al     
illness has be5 made1 su* election %all 
include an add5dum t specifies su* items
 & s]vices & includes su* additional    
in=mation z may be specifi$ by !        
,secret>y4 ,su* program %all provide an 
updat$ add5dum describ$ 9 ! prec$+      
s5t5ce to su* individual if1 :ile su*   
election is 9 effect ) respect to su*   
individual1 su* program makes any       
alt]ation to ! add5dum provid$ to su*   
individual at ! "t ( su* election44  7k7
 ,m$ical review ( hospice outli]s & c>e 
unrelat$ to t]m9al condition  7#a7 ,9   
g5]al  7,a7 ,m$ical review ,section     
#ahad7;a77#g7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acie;f7a77#g77 is      
am5d$-- 7i7 9 subp>agraph 7,d71 by /rik+
 & at ! end2  7ii7 9 subp>agraph 7,e71  
by ins]t+ & be=e ! date ( ! enactm5t (  

subp>agraph 7,f71 aft] subp>agraph12 &  
7iii7 by add+ at ! end ! foll[+ new     
subp>agraph3  7,f7 beg9n+ on ! date t is
 #e ye>s aft] ! date ( ! enactm5t ( ?is 
subp>agraph1 9 ! case ( hospice c>e     
provid$ an individual = m ?an #ij days  
by a hospice program ) ab]rant bill+    
patt]ns 7z det]m9$ by ! ,secret>y71 !   
hospice c>e provid$ to su* individual is
 subject to prepaym5t m$ical review 79  
accordance ) proc$ures e/abli%$ by !    
,secret>y72 &  4  7,b7 ,te*nical exp]t  
panel  7i7 ,9 g5]al ,! ,secret>y (      
,heal? & ,human ,s]vices %all e/abli% a 
te*nical exp]t panel = purposes (       
e/abli%+ /&>ds = id5tify+ a hospice     
program ) a hi/ory ( ab]rant bill+      
patt]ns "u section #ahad7;a77#g77;,f7 ( 
! ,social ,security ,act1 z add$ by     
subp>agraph 7,a74 ,9 mak+ recomm5dations
 ) respect to su* /&>ds1 su* panel %all 
take into acc\nt ! results ( prepaym5t  
m$ical reviews conduct$ "u section      
#ahff7;j77#aj77;,d7 ( su* ,act1 z add$  
by subsection 7a74  7ii7 ,,faca waiv] ,!

 provisions ( *apt] #aj ( title #e1     
,unit$ ,/ates ,code1 %all n apply to !  
panel e/abli%$ "u clause 7i74  7#b7     
,prepaym5t m$ical review requirem5t     
,section #ahab7;d77#b7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acie;d7d77#b77 is am5d$ by add+ at !   
end ! foll[+ new subp>agraph3  7,e7     
,not)/&+ any o!r provision ( ?is title1 
9 ! case ( items & s]vices 7o!r ?an     
items & s]vices describ$ 9 ! matt]      
foll[+ clause 7ii77,,ii7 ( subp>agraph  
7,a77 furni%$ on or aft] ,octob] #a1    
#bjbg1 to an individual ) an election 9 
effect "u p>agraph 7#a7 by a provid] (  
s]vices or suppli]1 if su* provid] (    
s]vices or suppli] indicates t su* items
 & s]vices are unrelat$ to !            
individual's condition ) respect to :i* 
a diagnosis ( t]m9al illness has be5    
made1 no paym5t may be made "u ?is title
 = su* items & s]vices be=e ! ,secret>y 
has conduct$ a m$ical review ( su* items
 & s]vices to det]m9e :e!r su* items &  
s]vices are unrelat$ to su* condition4  

,su* review %all include a review ( any 
add5dum describ$ 9 p>agraph 7#a7 includ$
 9 su* election4  4  7#c7 ,fund+ ,!     
,secret>y ( ,heal? & ,human ,s]vices    
%all provide = ! transf]1 f ! ,f$]al    
,hospital ,insurance ,tru/ ,fund        
e/abli%$ "u section #ahag ( ! ,social   
,security ,act 7#db ,u4,s4,c4 #acie;i7  
to ! ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices
 ,program ,managem5t ,acc\nt1 (         
#bj1jjj1jjj = fiscal ye> #bjbg1 to rema9
 available until exp5d$1 = purposes (   
c>ry+ out ! am5dm5ts made by ?is        
subsection4  7l7 ,provision (           
explanation ( b5efits ^u hospice        
election  7#a7 ,9 g5]al ,section #ahjf (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #acie;b-#g7 is am5d$ by add+ at ! end !
 foll[+ new subsection3  7d7 ,provision 
( explanation ( b5efits ^u hospice      
election ,! ,secret>y %all furni% to ea*
 individual :o makes an election        
describ$ 9 section #ahab7;d77#a71 n lat]
 ?an #ae days aft] su* individual makes 
su* election1 a notice t--  7#a7        

specifies-- 7,a7 ! effective date ( su* 
election2  7,b7 ! hospice program t w be
 furni%+ hospice c>e to su* individual2 
7,c7 ! telephone numb] & address ( su*  
program2  7,d7 ! physician1 physician   
assi/ant1 or nurse practition] :o made !
 c]tification describ$ 9 section        
#ahad7;a77#g77;,a77i77,i7 ) respect to  
su* individual2  7,e7 ! toll-free       
telephone numb] ( ! m$ic>e adm9i/rative 
contractor responsible = process+ claims
 = su* c>e2  7#b7 in=ms su* individual (
 ! waiv] ( rights describ$ 9 section    
#ahab7;d77#b77;,a72  7#c7 includes a    
/atem5t :i* indicates t1 because errors 
d occur & because ,m$ic>e wa/e1 fraud1 &
 abuse is a significant problem1 su*    
individual %\ld c>efully *eck !         
individual's hospice election in=mation 
& if su* individual suspects ,m$ic>e    
wa/e1 fraud1 or abuse ) respect to !    
provision ( su* c>e1 ! individual %\ld  
contact ! toll-free phone numb]         
#a-hjj-,,m$ic>e & a toll-free phone     
numb] ma9ta9$ by ! ,inspector ,g5]al ( !

 ,dep>tm5t ( ,heal? & ,human ,s]vices = 
! receipt ( compla9ts & in=mation ab\t  
wa/e1 fraud1 & abuse 9 ! provision or   
bill+ ( s]vices "u ?is title2 &  7#d7   
includes any o!r in=mation det]m9$      
appropriate by ! ,secret>y4  4  7#b7    
,fund+ ,! ,secret>y ( ,heal? & ,human   
,s]vices %all provide = ! transf] f !   
,f$]al ,hospital ,insurance ,tru/ ,fund 
e/abli%$ "u section #ahag ( ! ,social   
,security ,act 7#db ,u4,s4,c4 #acie;i7  
to ! ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices
 ,program ,managem5t ,acc\nt (          
#aj1jjj1jjj = fiscal ye> #bjbg1 to rema9
 available until exp5d$1 = purposes (   
c>ry+ out ! am5dm5t made by p>agraph    
7#a74  7#c7 ,effective date ,! am5dm5t  
made by p>agraph 7#a7 %all apply to     
individuals mak+ elections describ$ 9   
section #ahab7;d77#a7 ( ! ,social       
,security ,act 7#db ,u4,s4,c4           
#acie;d7d77#a77 on or aft] ! date t is  
#a ye> aft] ! date ( ! enactm5t ( ?is   
,act4  7m7 ,m$ical review ( hospice c>e 
contractor requirem5ts  7#a7 ,9 g5]al ,!

 ,secret>y ( ,heal? & ,human ,s]vices 79
 ?is subsection ref]r$ to z ! ,secret>y7
 %all require any entity p]=m+ m$ical   
review "u contract ) ! ,secret>y (      
hospice c>e furni%$ "u "p ,a ( title    
,,xviii ( ! ,social ,security ,act 7#db 
,u4,s4,c4 #acie;c et seq47 to1 ) respect
 to su* reviews p]=m$ on or aft] ,janu>y
 #a1 #bjbh1 utilize only individuals :o 
h receiv$ specializ$ in/ruction on !    
philosophy beh9d hospice c>e & m$ical   
progno/ication 7z specifi$ by !         
,secret>y7 9 p]=m+ su* reviews4 ,9 s    
specify+ su* in/ruction & 9 updat+ su*  
in/ruction1 ! ,secret>y %all consult )  
hospice programs z to ! cont5t ( su*    
in/ruction4  7#b7 ,publication ,!       
,secret>y %all make any in/ruction      
specifi$ = purposes ( p>agraph 7#a7     
publicly available on ! website ( !     
,c5t]s = ,m$ic>e  ,m$icaid ,s]vices4    
7#c7 ,report ,n lat] ?an ,octob] #a1    
#bjbh1 ! ,secret>y %all submit to       
,congress a report on activities relat+ 
to ! m$ical review ( hospice c>e furni%$

 "u "p ,a ( title ,,xviii ( ! ,social   
,security ,act 7#db ,u4,s4,c4 #acie;c et
 seq474 ,su* report %all include--  7,a7
 ) respect to ! m$ical review ( hospice 
c>e p]=m$ dur+ ! p]iod beg9n+ on ,janu>y
 #a1 #bjbj1 & end+ on ,decemb] #ca1     
#bjbe1 ! accuracy rates ( su* reviews :5
 p]=m$ by-- 7i7 m$ic>e adm9i/rative     
contractors2  7ii7 recov]y audit        
contractors2  7iii7 supplem5tal m$ical  
review contractors2 &  7iv7 uni=m       
program integrity contractors2  7,b7 !  
total numb] ( hospice claims submitt$   
dur+ ! p]iod describ$ 9 subp>agraph 7,a7
 subject to m$ical review2  7,c7 !      
p]c5tage ( su* claims t 7 d5i$ & appeal$
 & ! p]c5tage ( su* claims s appeal$ t 7
 ov]turn$ on appeal1 brok5 d[n by ! type
 ( contractor conduct+ review ( su*     
claims & by ea* level ( appeal2  7,d7 a 
li/ ( m$ical review projects relat+ to  
hospice c>e und]tak5 by contractors     
describ$ 9 subp>agraph 7,a72 &  7,e7    
actions ! ,secret>y w take to r$uce !   
audit burd5 on hospice programs ) claims

 select$ = m$ical review "u multiple    
projects describ$ 9 subp>agraph 7,d7 &  
to m9imize ! numb] ( d5ials ( claims =  
hospice c>e t are ov]turn$ on appeal4   
7n7 ,requir+ face-to-,face enc\nt]s be=e
 rec]tifications ( t]m9al illness       
,section #ahad7;a77#g7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acie;f7a77#g77 is am5d$--  7#a7 9      
subp>agraph 7,d7-- 7,a7 9 ! matt] prec$+
 clause 7i71 by ins]t+ 1 & be=e ,octob] 
#a1 #bjbg aft] #bjaa2 &  7,b7 by /rik+ &
 at ! end2 &  7#b7 by add+ at ! end !   
foll[+ new subp>agraph3  7,f7 on & aft] 
,octob] #a1 #bjbg1 n m ?an #cj days be=e
 ea* rec]tification describ$ 9          
subp>agraph 7,a77ii7 is made ) respect  
to an individual1 a hospice physician1  
hospice nurse practition]1 or hospice   
physician assi/ant has a face-to-face   
enc\nt] 7:i* may1 ) respect to any su*  
rec]tification made = a #fj-;day p]iod  
describ$ 9 su* subp>agraph1 be conduct$ 
via teleheal?1 b only if a regi/]$      
nurse1 lic5s$ practical nurse1 or home  

heal? aide employ$ by ! hospice program 
furni%+ hospice c>e to su* individual is
 physically pres5t ) su* individual dur+
 su* enc\nt]7 ) su* individual to ga!r  
cl9ical f9d+s to det]m9e su*            
individual's cont9u$ eligibility =      
hospice c>e2 &  4  7o7 ,ensur+ m$ical   
director & physician availability  7#a7 
,9 g5]al ,section #ahfa7;dd7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          
#aciex7dd77 is am5d$--  7,a7 9 p>agraph 
7#b7-- 7i7 9 subp>agraph 7,f71 by /rik+ 
& at ! end2  7ii7 by r$esignat+         
subp>agraph 7,g7 z subp>agraph 7,i72 &  
7iii7 by ins]t+ aft] subp>agraph 7,f7 ! 
foll[+ new subp>agraphs3  7,g7 has a    
m$ical director responsible = ! m$ical  
compon5t ( hospice c>e provid$ by su*   
program :o-- 7i7 is a doctor ( m$ic9e or
 o/eopa?y lic5s$ to practice 9 ! ,/ate 9
 :i* su* program is locat$2 &  7ii7     
subject to p>agraph 7#f71 is n ! m$ical 
director ( m ?an #a o!r hospice program2
  7,h7 ensures t ! m$ical director      
describ$ 9 subp>agraph 7,g7 or a        

physician memb] ( ! gr\p describ$ 9     
subp>agraph 7,b7 is available = imm$iate
 consultation 7:i* may be ?r\gh         
teleheal?7 :5 hospice c>e is provid$ 9  
an individual's home2 &  2 &  7,b7 by   
add+ at ! end ! foll[+ new p>agraph3    
7#f7 ,! ,secret>y may waive ! requirem5t
 describ$ 9 p>agraph 7#b77;,g77ii7 )    
respect to ! m$ical director ( a hospice
 program if det]m9$ appropriate by !    
,secret>y on a case-by-case basis4 ,9   
det]m9+ :e!r to grant a waiv] "u !      
prec$+ s5t5ce1 ! ,secret>y %all take    
into consid]ation--  7,a7 ! av]age daily
 c5sus = ea* hospice program ) respect  
to :i* su* director is m$ical director2 
7,b7 ! geographic areas s]v$ by su*     
programs2 &  7,c7 any o!r in=mation     
det]m9$ appropriate by ! ,secret>y4  4  
7#b7 ,effective date ,! am5dm5ts made by
 p>agraph 7#a7 %all apply beg9n+ ,janu>y
 #a1 #bjbi4  7p7 ,report on hospice     
accr$it+ organizations ,n lat] ?an #b   
ye>s aft] ! date ( ! enactm5t ( ?is     
,act1 ! ,comptroll] ,g5]al ( ! ,unit$   

,/ates %all submit to ,congress a report
 on ! ,secret>y ( ,heal? & ,human       
,s]vices' 79 ?is subsection ref]r$ to z 
! ,secret>y7 ov]sight ( hospice program 
accr$it+ organizations4 ,su* report %all
 include ! foll[+3 7#a7 ,an analysis (  
defici5cies relat+ to quality ( c>e f\nd
 pursuant to surveys conduct$ "u section
 #ahbb7;a7 ( ! ,social ,security ,act   
7#db ,u4,s4,c4 #acie;i-#f7;a77 foll[+   
compla9ts :5 su* surveys 7 ( hospice    
programs accr$it$ by su* an organization
 & su* surveys 7 conduct$ by su* an     
organization comp>$ to su* defici5cies s
 f\nd foll[+ su* compla9ts :5 su*       
surveys 7 ( hospice programs c]tifi$ by 
,/ate or local survey ag5cies & su*     
surveys 7 conduct$ by su* ag5cies4  7#b7
 ,a li/ ( hospice programs det]m9$ by ! 
,secret>y n to be 9 compliance ) all    
requirem5ts applicable to su* programs1 
along ) a li/ ( ! accr$it+ organization 
( ea* su* program4  7#c7 ,a li/ (       
hospice programs t h be5 deactivat$1    
t]m9at$1 or inve/igat$ due to conc]ns   

relat+ to wa/e1 fraud1 or abuse1 along )
 a li/ ( ! accr$it+ organization ( ea*  
su* program4  7#d7 ,an analysis ( any   
conflicts ( int]e/ ( hospice program    
accr$it+ organizations4  7#e7 ,p]=mance 
data = hospice program accr$it+         
organizations4  #c4 ,paym5t re=ms =     
hospice c>e furni%$ "u ! ,m$ic>e program
  7a7 ,adju/+ paym5ts = hospice c>e     
7#a7 ,9 g5]al ,section                  
#ahad7;i77#a77;,c7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acie;f7i77#a77;,c77 is am5d$-- 7,a7 9  
clause 7iii7--  7i7 by mov+ su* clause  
#f ems to ! left2  7ii7 by /rik+ ,)     
respect to & ins]t+ ,except z provid$ "u
 clauses 7viii7 ?r\gh 7x71 ) respect to2
  7iii7 by ins]t+ 9 a sett+ 7z specifi$ 
by ! ,secret>y = purposes ( clause      
7vii77 aft] hospice c>e furni%$2  7iv7  
by ins]t+ = su* sett+ aft] paym5t rates 
9 effect2 &  7v7 by /rik+ "u ?is clause 
& ins]t+ "u ?is subp>agraph2  7,b7 9    
clause 7iv71 by /rik+ clause 7ii77,,vii7
 or 7iii7 ea* place su* phrase appe>s & 

ins]t+ clause 7iii7 or 7iv7 ( p>agraph  
7#b77;,d7 or clause 7ii77,,vii71 7iii71 
7viii71 7ix71 or 7x7 9 ea* su* place2 & 
7,c7 by add+ at ! end ! foll[+ new      
clauses3  7vii7 ,prior to ! beg9n+ ( a  
specifi$ fiscal ye> 7z def9$ 9 clause   
7xi771 ! ,secret>y %all specify         
p]c5tages by :i* ! paym5t rates =       
hospice c>e consi/+ ( s]vices o!r ?an   
r\t9e home c>e 7&1 = specifi$ ye>s      
beg9n+ on or aft] ,octob] #a1 #bjcd1 =  
hospice c>e consi/+ ( r\t9e home c>e &  
o!r s]vices includ$ 9 hospice c>e7 9    
effect = ! prec$+ fiscal ye> %all be    
adju/$ 9 su* specifi$ fiscal ye> to     
align su* rates ) ! co/s ( su* c>e4 ,9  
specify+ su* p]c5tages--  7,i7 !        
,secret>y %all take into acc\nt *anges 9
 ! av]age co/ ( su* c>e & su* o!r       
factors z det]m9$ appropriate by !      
,secret>y2 &  7,,ii7 ! ,secret>y may    
specify diff]5t p]c5tages = su* c>e bas$
 on ! sett+ 7z specifi$ by ! ,secret>y7 
9 :i* su* c>e is furni%$4  7viii7  7,i7 
,) respect to r\t9e home c>e furni%$    

dur+ fiscal ye> #bjcj1 ! paym5t rates = 
su* c>e %all be equal to ! sum (-- 7aa7 
a p] diem am\nt 7:i* may include an a   
case mix adju/m5t to acc\nt = v>iations 
9 co/ among diff]5t units ( s]vice7     
reflect+ ! co/ ( r\t9e home c>e n       
consi/+ ( direct pati5t c>e = nurs+ c>e1
 physical !rapy1 occupational !rapy1    
spee*-language pa?ology s]vices1 m$ical 
social s]vices 7o!r ?an c\nsel+         
s]vices71 home heal? aide s]vices1 &    
physician s]vices 7o!r ?an su* s]vices t
 are consid]$ adm9i/rative s]vices72 &  
7bb7 subject to su* frequ5cy limits z   
may be specifi$ by ! ,secret>y1 a p]    
visit am\nt 7:i* may v>y dep5d+ on !    
type & duration ( ! visit1 z det]m9$    
appropriate by ! ,secret>y7 reflect+ !  
co/ ( r\t9e home c>e consi/+ ( direct   
pati5t c>e exclud$ f ! p] diem am\nt    
e/abli%$ "u item 7aa7 7o!r ?an1 9 ! case
 ( su* c>e furni%$ at a skill$ nurs+    
facility or nurs+ facility 7z def9$ 9   
section #aiai7;a771 ! compon5t ( su*    
rates attributable to home heal? aide   

s]vices74  7,,ii7 ,) respect to r\t9e   
home c>e furni%$ dur+ fiscal ye> #bjca  
or a subsequ5t fiscal ye>1 ! paym5t     
rates = su* c>e %all be equal to ! sum  
(--  7aa7 ! p] diem am\nt attributable  
to hospice c>e describ$ 9 subclause     
7,i77aa7 9 effect "u ?is clause = !     
prec$+ fiscal ye>1 adju/$1 9 ! case ( a 
specifi$ fiscal ye>1 by ! p]c5tages     
specifi$ pursuant to clause 7vii7 = su* 
specifi$ fiscal ye>1 increas$ by ! m>ket
 basket p]c5tage increase 7z def9$ 9    
section #ahhf7;b77#c77;,b77iii77 = !    
fiscal ye> 7r$uc$ 9 accordance ) clause 
7iv772 &  7bb7 ! p] visit am\nt =       
hospice c>e describ$ 9 subclause        
7,i77bb7 9 effect "u ?is clause = !     
prec$+ fiscal ye>1 adju/$1 9 ! case ( a 
specifi$ fiscal ye>1 by ! p]c5tages     
specifi$ pursuant to clause 7vii7 = su* 
specifi$ fiscal ye>1 increas$ by su*    
m>ket basket p]c5tage increase = !      
fiscal ye> 7r$uc$ 9 accordance ) clause 
7iv774  7,,iii7 ,= purposes ( ?is       
clause1 ! t]m visit means1 ) respect to 

an individual receiv+ hospice c>e f a   
hospice program1 9-p]son contact ) su*  
individual by /aff ( su* program 7or by 
o!rs "u arrangem5ts ) su* program71 n   
includ+ any su* contact conduct$ via    
teleheal? or any o!r =m (               
telecommunications te*nology4  7ix7 7,i7
 ,) respect to r\t9e home c>e consi/+ ( 
specifi$ hospice c>e 7z def9$ 9         
subclause 7,,ii77 furni%$ by1 or "u     
arrangem5ts made by1 a hospice program  
dur+ ! p]iod beg9n+ on ,octob] #a1      
#bjbg1 & end+ on ,septemb] #cj1 #bjcb1 9
 lieu ( ! rates o!rwise payable "u ?is  
subp>agraph = su* r\t9e home c>e1 !     
,secret>y %all pay to ! hospice program 
furni%+ su* c>e an am\nt equal to #djj  
p]c5t ( ! am\nt payable = r\t9e home c>e
 furni%$ 9 fiscal ye> #bjbg1 increas$ by
 ! m>ket basket p]c5tage increase 7z    
def9$ 9 section #ahhf7;b77#c77;,b77iii77
 = ! fiscal ye> 7r$uc$ 9 accordance )   
clause 7iv771 or su* o!r am\nt det]m9$  
appropriate by ! ,secret>y 7:i* may v>y 
bas$ on ! type ( s]vice furni%$7 = ea*  

day dur+ :i* su* specifi$ hospice c>e 0 
furni%$4  7,,ii7 ,= purposes ( subclause
 7,i71 ! t]m specifi$ hospice c>e means 
any ( ! foll[+ items & s]vices3 7aa7    
,palliative *emo!rapy or radiation      
furni%$ "u ! sup]vision ( an oncologi/ &
 9 accordance ) accept$ cl9ical         
guidel9es4  7bb7 ,palliative radiation  
!rapy furni%$ "u ! sup]vision ( an      
oncologi/ & 9 accordance ) accept$      
cl9ical guidel9es4  7cc7 ,subject to su*
 frequ5cy limitations z ! ,secret>y may 
e/abli%1 palliative blood transfusions  
furni%$ to an individual diagnos$ ) a   
blood canc] & furni%$ "u ! sup]vision ( 
an oncologi/ & 9 accordance ) accept$   
cl9ical guidel9es4  7dd7 ,palliative    
dialysis furni%$ "u ! sup]vision ( a    
nephrologi/1 b only if-- 7,,aa7 !       
individual receiv+ su* palliative       
dialysis 0 receiv+ dialysis treatm5ts   
prior to mak+ ! election "u section     
#ahab7;d72 & 7,,bb7 su* individual has  
receiv$ few] ?an #aj sessions ( su*     
palliative 9-c5t] or home hemodialysis  

or ! equival5t = p]itoneal dialysis or  
o!r modalities 7or1 9 ! case su*        
individual has receiv$ #aj or m su*     
sessions or ! equival5t ( su* sessions1 
su* session or equival5t ( su* session  
is subject to prior au?orization74  7x7 
,) respect to hospice c>e consi/+ (     
s]vices o!r ?an r\t9e home c>e furni%$  
dur+ #bjcj or a subsequ5t fiscal ye>1 ! 
paym5t rates = su* c>e %all be equal to 
! rates 9 effect = su* c>e = ! prec$+   
fiscal ye>1 adju/$1 9 ! case ( a        
specifi$ fiscal ye>1 by ! p]c5tages     
specifi$ pursuant to clause 7vii7 = su* 
specifi$ fiscal ye>1 increas$ by ! m>ket
 basket p]c5tage increase 7z def9$ 9    
section #ahhf7;b77#c77;,b77iii77 = !    
fiscal ye> 7r$uc$ 9 accordance ) clause 
7iv774  7xi7 ,= purposes ( ?is          
subp>agraph1 ! t]m specifi$ fiscal ye>  
means fiscal ye>s #bjcj1 #bjce1 & #bjdj4
  7xii7 7,i7 ,! ,secret>y %all1 )       
respect to co/ report+ p]iods beg9n+    
dur+ an applicable fiscal ye> 7z def9$ 9
 subclause 7,,iii771 conduct an audit ( 

a repres5tative sample ( co/ reports    
submitt$ by hospice programs4  7,,ii7 ,!
 ,secret>y %all1 = ea* applicable fiscal
 ye>1 conv5e a te*nical exp]t panel =   
purposes ( review+ ! me?odology &       
results ( ! audit conduct$ "u subclause 
7,i7 ) respect to su* applicable fiscal 
ye>4  7,,iii7 ,= purposes ( ?is clause1 
! t]m applicable fiscal ye> means fiscal
 ye>s #bjbf1 #bjca1 & #bjcf4  7,,iv7 ,! 
provisions ( *apt] #aj ( title #e1      
,unit$ ,/ates ,code1 %all n apply to !  
panel e/abli%$ "u subclause 7,,ii74     
7,v7 ,! ,secret>y %all provide = !      
transf]1 f ! ,f$]al ,hospital ,insurance
 ,tru/ ,fund e/abli%$ "u section #ahag  
to ! ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices
 ,program ,managem5t ,acc\nt1 (         
#aj1jjj1jjj = ea* ( fiscal ye>s #bjbg1  
#bjcb1 & #bjcg1 to rema9 available until
 exp5d$1 = purposes ( c>ry+ out ?is     
clause4  4  7#b7 ,outli] paym5ts        
,section #ahad7;i7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #acie;f7i77 is     
am5d$-- 7,a7 by r$esignat+ p>agraph 7#g7

 z p>agraph 7#h72 &  7,b7 by ins]t+ aft]
 p>agraph 7#f7 ! foll[+ new p>agraph3   
7#g7 7,a7 ,subject to subp>agraph 7,b71 
) respect to r\t9e home c>e furni%$ dur+
 a fiscal ye> beg9n+ on or aft] ,octob] 
#a1 #bjcb1 ! ,secret>y may1 if det]m9$  
appropriate by ! ,secret>y1 provide an  
additional paym5t = types ( su* c>e 7su*
 z specifi$ hospice c>e 7z def9$ 9      
p>agraph 7#a77;,c77ix777 specifi$ by !  
,secret>y to acc\nt = unusual v>iations 
9 ! type or am\nt ( su* r\t9e home c>e4 
7,b7  7i7 ,! total am\nt ( additional   
paym5ts e/imat$ to be made "u           
subp>agraph 7,a7 = r\t9e home c>e       
furni%$ dur+ a fiscal ye> may n exce$ #e
 p]c5t ( ! total am\nt ( paym5ts e/imat$
 to be made = su* c>e furni%$ dur+ su*  
fiscal ye> )\t application ( ?is        
p>agraph = su* fiscal ye>4  7ii7 ,!     
total am\nt ( additional paym5ts e/imat$
 to be made "u subp>agraph 7,a7 = r\t9e 
home c>e furni%$ dur+ a fiscal ye> to an
 individual hospice program may n exce$ 
#aj p]c5t ( ! total am\nt ( paym5ts     

e/imat$ to be made = su* c>e furni%$    
dur+ su* fiscal ye> by su* program )\t  
application ( ?is p>agraph = su* fiscal 
ye>4  7,c7 ,! ,secret>y %all r$uce any  
p] diem rate applicable "u p>agraph 7#a7
 to r\t9e home c>e furni%$ dur+ ! fir/  
fiscal ye> = :i* paym5ts are made "u    
subp>agraph 7,a7 by su* proportion z w  
result1 n tak+ into acc\nt any          
additional paym5ts made "u subp>agraph  
7,a7 = su* c>e furni%$ dur+ su* fiscal  
ye>1 9 an aggregate r$uction ( #e p]c5t 
9 paym5t = su* c>e furni%$ dur+ su*     
fiscal ye>4  4  7#c7 ,plan ( c>e        
requirem5ts  7,a7 ,9 g5]al ,section     
#ahad7;a77#g77;,b7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acie;f7a77#g77;,b77 is am5d$ by ins]t+ 
&1 ) respect to ! e/abli%m5t ( su* plan1
 9 ! case su* plan includes ! furni%+ ( 
specifi$ hospice c>e 7z def9$ 9         
subsection 7i77#a77;,c77x77,,ii771 by a 
nephrologi/ 7if su* c>e is c>e describ$ 
9 item 7dd7 ( su* subsection7 or by an  
oncologi/ 7if su* c>e is c>e describ$ 9 

any ( items 7aa7 ?r\gh 7cc7 ( su*       
subsection7 :o does n h a significant   
own]%ip int]e/ 91 or a significant      
f9ancial relation%ip )1 su* hospice     
program1 z det]m9$ by ! ,secret>y1 &1 ) 
respect to ! p]iodic review ( su* plan1 
9 ! case su* plan includes ! furni%+ (  
specifi$ hospice c>e 7z def9$ 9         
subsection 7i77#a77;,c77x77,,ii771 by ! 
nephrologi/ sup]vis+ ! furni%+ ( su* c>e
 7if su* c>e is describ$ 9 item 7dd7 (  
su* subsection7 or by ! oncologi/       
sup]vis+ ! furni%+ ( su* c>e 7if su* c>e
 is describ$ 9 any ( items 7aa7 ?r\gh   
7cc7 ( su* subsection7 aft] ( ! hospice 
program4  7,b7 ,effective date ,!       
am5dm5t made by subp>agraph 7,a7 %all   
apply ) respect to writt5 plans =       
provid+ hospice c>e develop$ or review$ 
on or aft] ,octob] #a1 #bjbg4  7#d7     
,exclud+ home heal? aide s]vices &      
homemak] f ! def9ition ( hospice c>e 9  
c]ta9 circum/ances  7,a7 ,9 g5]al       
,section #ahfa7;dd77#a77;,d77i7 ( !     
,social ,security ,act 7#db ,u4,s4,c4   

#aciex7dd77#a77;,d77i77 is am5d$ by     
ins]t+ 9 ! case su* individual is n     
resid+ 9 a skill$ nurs+ facility or a   
nurs+ facility1 be=e s]vices ( a4  7,b7 
,homemak] s]vices ,section              
#ahfa7;dd77#a77;,d77ii7 ( ! ,social     
,security ,act 7#db ,u4,s4,c4           
#aciex7dd77#a77;,d77ii77 is am5d$ by    
ins]t+ 7b only if su* individual is n   
resid+ 9 a skill$ nurs+ facility or a   
nurs+ facility 7z def9$ 9 section       
#aiai7;a77 or1 if su* individual is     
resid+ 9 su* a skill$ nurs+ facility or 
nurs+ facility1 only if su* s]vices are 
provid$ on a volunte] basis 9 accordance
 ) p>agraph 7#b77;,e77 aft] homemak]    
s]vices4  7,c7 ,effective date ,!       
am5dm5ts made by subp>agraphs 7,a7 &    
7,b7 %all apply to items & s]vices      
furni%$ on or aft] ,octob] #a1 #bjbi4   
7#e7 ,con=m+ adju/m5t to paym5t cap     
,section #ahad7;i77#b77;,b7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#acie;f7i77#b77;,b77 is am5d$-- 7,a7 9  
clause 7i71 by /rik+ clause 7ii7 &      

ins]t+ clauses 7ii7 ?r\gh 7iv72  7,b7 9 
clause 7ii71 by ins]t+ 1 & subject to   
clause 7iii71 aft] subp>agraph 7,a72    
7,c7 by /rik+ clause 7iii7 & ins]t+ !   
foll[+ new clause3  7iii7 ,= purposes ( 
subp>agraph 7,a71 9 ! case ( a specifi$ 
fiscal ye> 7z def9$ 9 p>agraph          
7#a77;,c77xi771 ! cap am\nt = su* ye> is
 ! cap am\nt "u ?is subp>agraph = !     
prec$+ fiscal ye>1 adju/$ by ! e/imat$  
p]c5tage *ange 9 ! total am\nt ( paym5t 
made "u ?is "p = hospice c>e            
attributable to application ( ! am5dm5ts
 made by section #c7;a77#a7 ( ! ,hospice
 ,c>e ,acc\ntability1 ,re=m1 & ,en=cem5t
 ,act ( #bjbf = su* specifi$ fiscal ye> 
& !n increas$ by ! m>ket basket p]c5tage
 increase 7z def9$ 9 section            
#ahhf7;b77#c77;,b77iii77 = su* specifi$ 
fiscal ye> 7r$uc$ 9 accordance )        
p>agraph 7#a77;,c77iv774  2 &  7,d7 by  
add+ at ! end ! foll[+ new clause3  7iv7
 ,= purposes ( subp>agraph 7,a71 &      
subject to clause 7iii71 = a fiscal ye> 
beg9n+ on or aft] ,octob] #a1 #bjce1 !  

cap am\nt = su* ye> is ! cap am\nt "u   
?is subp>agraph = ! prec$+ fiscal ye>1  
increas$ by ! m>ket basket p]c5tage     
increase 7z def9$ 9 section             
#ahhf7;b77#c77;,b77iii77 = su* fiscal   
ye> 7r$uc$ 9 accordance ) p>agraph      
7#a77;,c77iv774  4  7b7 ,wage adju/+    
caps  7#a7 ,9 g5]al ,section            
#ahad7;i77#b7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acie;f7i77#b771 z am5d$
 by subsection 7a71 is fur!r am5d$--    
7,a7 9 subp>agraph 7,a7-- 7i7 by /rik+  
cap am\nt = ! ye> 7comput$ "u           
subp>agraph 7,b77 & ins]t+ wage-adju/$  
cap 7z def9$ 9 subp>agraph 7,b77 = su*  
program & ye>2 &  7ii7 by /rik+         
subp>agraph 7,c7 & ins]t+ subp>agraph   
7,e72  7,b7 by r$esignat+ subp>agraphs  
7,b7 ?r\gh 7,d7 z subp>agraphs 7,d7     
?r\gh 7,f71 respectively2  7,c7 by      
ins]t+ aft] subp>agraph 7,a7 ! foll[+   
new subp>agraphs3  7,b7 ,= purposes (   
subp>agraph 7,a71 ! t]m wage-adju/$ cap 
means1 ) respect to a hospice program & 
a ye>1 ! product (--  7i7 ! wage index  

ratio 7z comput$ "u subp>agraph 7,c77 = 
su* program & ye>2 &  7ii7 ! cap am\nt =
 su* ye> 7z comput$ "u subp>agraph      
7,d774  7,c7 ,= purposes ( subp>agraph  
7,b71 ! wage index ratio = a hospice    
program & a ye> is ! ratio (-- 7i7 !    
aggregate paym5ts to su* program = su*  
ye> "u p>agraph 7#a72 to  7ii7 !        
aggregate paym5ts to su* program = su*  
ye> "u su* p>agraph t w\ld h be5 made _h
 su* paym5ts n be5 subject to any wage  
adju/m5t4  2  7,d7 9 subp>agraph 7,d71 z
 s r$esignat$--  7i7 by /rik+           
subp>agraph 7,a7 ea* place x appe>s &   
ins]t+ subp>agraph 7,b7 9 ea* su* place2
 &  7ii7 by add+ at ! end ! foll[+ new  
clause3  7v7 ,not)/&+ ! prec$+          
provisions ( ?is subp>agraph1 = a fiscal
 ye> beg9n+ on or aft] ,octob] #a1      
#bjbf1 ! cap am\nt o!rwise det]m9$ "u   
?is subp>agraph = su* fiscal ye> %all be
 decreas$ by ! same p]c5tage r$uction   
7if any7 appli$ to ! am\nt ( paym5t made
 "u ?is "p = su* fiscal ye> "u an ord]  
issu$ pursuant to section #bea ( !      

,balanc$ ,budget & ,em]g5cy ,deficit    
,control ,act ( #aihe4 ,any r$uction to 
! cap am\nt = a fiscal ye> "u ! prec$+  
s5t5ce %all n be tak5 into acc\nt =     
purposes ( det]m9+ ! cap am\nt = any    
succe$+ fiscal ye>4  2 &  7,e7 by add+  
at ! end ! foll[+ new subp>agraph3  7,g7
 ,n lat] ?an #a ye> aft] ! date ( !     
enactm5t ( ?is subp>agraph1 & annually  
!reaft]1 ! ,secret>y %all submit to     
,congress & make public on ! website ( !
 ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices a  
report on ! calculation ( hospice       
programs' cap am\nts "u ?is p>agraph4   
,su* report %all conta91 ) respect to   
ea* ( ! #e mo/ rec5t acc\nt+ ye>s = :i* 
data is available & ea* hospice program 
receiv+ paym5ts "u ?is section = hospice
 c>e furni%$ dur+ su* ye>1 ! foll[+3 7i7
 ,su* program's cap am\nt det]m9$ "u su*
 section4  7ii7 ,! p]c5tage ( su*       
program's cap am\nt paid to su* program 
= su* c>e4  7iii7 ,9 ! case paym5ts to  
su* program exce$$ su* cap1 any am\nt   
rec\p$ by ! ,secret>y ) respect to su*  

program4  7iv7 ,! live dis*>ge rate (   
su* program4  4  7#b7 ,implem5tation    
,not)/&+ any o!r provision ( law1 !     
,secret>y ( ,heal? & ,human ,s]vices may
 implem5t ! am5dm5ts made by p>agraph   
7#a7 by program in/ruction or o!rwise4  
7#c7 ,effective date ,! am5dm5ts made by
 subp>agraphs 7,a7 ?r\gh 7,c7 ( p>agraph
 7#a7 %all apply ) respect to paym5t =  
hospice c>e furni%$ dur+ fiscal ye>s    
beg9n+ on or aft] ,octob] #a1 #bjbg4    
7c7 ,modification ( requirem5ts relat+  
to %ort-,t]m inpati5t c>e  7#a7 ,9 g5]al
 ,section #ahfa7;dd7 ( ! ,social        
,security ,act 7#db ,u4,s4,c4           
#aciex7dd77 is am5d$--  7,a7 9 p>agraph 
7#a7-- 7i7 9 subp>agraph 7,g71 by /rik+ 
consecutively ov] long] ?an five days & 
ins]t+ = m ?an #e days dur+ any #ij-;day
 election p]iod 7or #fj-;day election   
p]iod1 z applicable7 describ$ 9 section 
#ahab7;d77#a72 &  7ii7 9 ! flu% matt]   
foll[+ subp>agraph 7,i71 by add+ at !   
end ! foll[+ new s5t5ce3 ,9 ! case ( an 
individual :o receives %ort-t]m inpati5t

 c>e describ$ 9 subp>agraph 7,g7 consi/+
 ( respite c>e dur+ an election p]iod & 
! furni%+ ( su* c>e is imm$iately prec$$
 by a hospital /ay 7:i* may include a   
/ay = obs]vation7 dur+ :i* su*          
individual made an election describ$ 9  
section #ahab7;d77#a7 = ! fir/ "t dur+  
su* individual's lifetime 7or if su* c>e
 is imm$iately prec$$ by ! furni%+ (    
hospice c>e consi/+ ( g5]al inpati5t c>e
 & su* g5]al inpati5t c>e is imm$iately 
prec$$ by su* a hospital /ay71 ! fir/   
cont9u\s #ae days ( su* c>e %all n be   
tak5 into acc\nt = purposes ( apply+ !  
limitation on ! numb] ( days dur+ :i*   
su* c>e may be furni%$ dur+ an election 
p]iod "u su* subp>agraph1 b only if su* 
individual does n h suffici5t c>egiv]   
support to be dis*>g$ to ! individual's 
home42 &  7,b7 9 p>agraph 7#b7--  7i7 9 
subp>agraph 7,a77iii7-- 7,i7 by /rik+   
provides assurances satisfactory to !   
,secret>y t & ins]t+ ensures t ! sum (2 
&  7,,ii7 by /rik+ #bj p]c5t & ins]t+   
#aj p]c5t 7or a high] p]c5t 7n to exce$ 

#bj p]c5t7 specifi$ by ! ,secret>y if   
det]m9$ necess>y by ! ,secret>y to      
ensure suffici5t access to su* inpati5t 
c>e72 &  7ii7 by add+ at ! end ! foll[+ 
flu% s5t5ce3  ,= purposes ( subp>agraph 
7,a77iii71 ! ,secret>y %all ensure t !  
limitation describ$ 9 su* subp>agraph is
 appli$1 to ! ext5t practicable1 on a   
real-"t basis4 4  7#b7 ,all[+ respite   
c>e to be furni%$ 9 resid5tial c>e      
facilities ,n lat] ?an ,octob] #a1      
#bjbg1 ! ,secret>y ( ,heal? & ,human    
,s]vices 79 ?is p>agraph ref]r$ to z !  
,secret>y7 %all revise section #dah4ajh 
( title #db1 ,code ( ,f$]al ,regulations
 7or a successor regulation7 to all[    
%ort-t]m inpati5t c>e consi/+ ( respite 
c>e 7z describ$ 9 section               
#ahfa7;dd77#a77;,g7 ( ! ,social         
,security ,act 7#db ,u4,s4,c4           
#aciex7dd77#a77;,g777 to be furni%$ 9   
resid5tial c>e facilities 7z def9$ by ! 
,secret>y7 t only provide c>e to        
individuals receiv+ hospice c>e 7z      
specifi$ by ! ,secret>y7 & t meet su*   

/&>ds relat+ to heal? & safety z !      
,secret>y may specify 7:i* may be bas$  
on ,/ate lic5sure requirem5ts applicable
 to su* facilities74  7#c7 ,effective   
date ,! am5dm5ts made by p>agraph 7#a7  
%all apply to hospice c>e furni%$ on or 
aft] ,octob] #a1 #bjbg4  7d7 ,hospital  
dis*>ge plann+ requirem5ts  7#a7 ,9     
g5]al ,section #ahfa7;ee77#b77;,d7 ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#aciex7ee77#b77;,d77 is am5d$-- 7,a7 by 
ins]t+ 1 home heal? s]vices1 aft]       
includ+ hospice c>e2  7,b7 by /rik+     
includ+ ! availability ( home heal?     
s]vices ?r\gh individuals & entities &  
ins]t+ ! foll[+3 includ+--  7i7 9 ! case
 ( individuals :o are likely to ne$ home
 heal? s]vices1 ! availability ( su*    
s]vices ?r\gh home heal? ag5cies  2     
7,c7 by /rik+ li/$ by ! hospital z      
available &1 9 ! case ( individuals :o  
are likely to ne$ po/-hospital ext5d$   
c>e s]vices1 & ins]t+ ! foll[+3  li/$ by
 ! hospital z available2 7ii7 9 ! case (
 individuals :o are likely to ne$       

po/-hospital ext5d$ c>e s]vices1  2     
7,d7 by /rik+ ! p]iod & ins]t+ 2 &2 &   
7,e7 by add+ at ! end ! foll[+ new      
clause3  7iii7 9 ! case ( individuals :o
 are likely eligible = hospice c>e1 !   
availability ( su* c>e 7includ+ !       
availability ( respite c>e describ$ 9   
subsection 7dd77#a77;,g77 ?r\gh hospice 
programs t p>ticipate 9 ! program "u ?is
 title & t s]ve ! area 9 :i* ! pati5t   
resides4  4  7#b7 ,effective date ,!    
am5dm5ts made by p>agraph 7#a7 %all     
apply ) respect to dis*>ges occurr+ on  
or aft] ,octob] #a1 #bjbg4  7e7 ,paym5t 
= respite c>e furni%$ 9 ! home  7#a7 ,9 
g5]al ,section #ahfa7;dd77#a7 ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#aciex7dd77#a77 is am5d$-- 7,a7 9       
subp>agraph 7,h71 by /rik+ & at ! end2  
7,b7 by r$esignat+ subp>agraph 7,i7 z   
subp>agraph 7,j72 &  7,c7 by ins]t+ aft]
 subp>agraph 7,h7 ! foll[+ new          
subp>agraph3  7,i7 %ort-t]m home respite
 c>e furni%$ to an individual on or aft]
 ,octob] #a1 #bjbi1 t-- 7i7 is furni%$ 9

 ! place ( resid5ce us$ z su*           
individual's home 7o!r ?an a skill$     
nurs+ facility1 a nurs+ facility 7z     
def9$ 9 section #aiai7;a771 an assi/$   
liv+ facility 7z def9$ by ! ,secret>y71 
or ano!r facility specifi$ by !         
,secret>y72  7ii7 is furni%$ on an      
int]mitt5t1 nonr\t9e1 & occasional      
basis2  7iii7 is furni%$ = n m ?an #abj 
h\rs dur+ any #ij-;day p]iod describ$ 9 
section #ahab7;d77#a7 7or1 9 ! case (   
any #fj-;day p]iod describ$ 9 su*       
section1 = n m ?an #hj h\rs dur+ su*    
p]iod72 &  7iv7 meets su* o!r           
requirem5ts z ! ,secret>y may specify4  
4  7#b7 ,paym5t rates ,section          
#ahad7;i77#a77;,c7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acie;f7i77#a77;,c771 z am5d$ by        
subsection 7a71 is fur!r am5d$--  7,a7 9
 clause 7iii71 by /rik+ ?r\gh 7x7 &     
ins]t+ ?r\gh 7x7 & clause 7xiii72 &     
7,b7 by add+ at ! end ! foll[+ new      
clause3  7xiii7 ,) respect to %ort-t]m  
home respite c>e furni%$ to an          

individual dur+ fiscal ye> #bjcj or a   
subsequ5t fiscal ye>1 ! rates payable = 
su* c>e %all be equal to ! sum ( ! p]   
diem rate e/abli%$ = r\t9e home c>e =   
su* fiscal ye> & an h\rly rate e/abli%$ 
by ! ,secret>y1 except t 9 no case may  
su* rate payable = su* %ort-t]m home    
respite c>e furni%$ 9 a #bd-;h\r p]iod  
exce$ ! rate ( paym5t = g5]al inpati5t  
c>e furni%$ dur+ su* a p]iod4  4