42 U.S.C. § 1395lll: Standardized post-acute care (PAC) assessment data for quality, payment, and discharge planning

standardized patient assessment data in accordance with subsection (b); data on quality measures under subsection (c)(1); and data on resource use and other measures under subsection (d)(1); require data described in subparagraph (A) to be standardized and interoperable so as to allow for the exchange of such data among such post-acute care providers and other providers and the use by such providers of such data that has been so exchanged, including by using common standards and definitions, in order to provide access to longitudinal information for such providers to facilitate coordinated care and improved Medicare beneficiary outcomes; and provide for the submission of standardized patient assessment data under this subchapter with respect to such providers; and enable comparison of such assessment data across all such providers to whom such data are applicable. a home health agency; a skilled nursing facility; an inpatient rehabilitation facility; and a long-term care hospital (other than a hospital classified under section 1395ww(d)(1)(B)(vi) of this title ). in the case of home health agencies, the instrument used for purposes of reporting and assessment with respect to the Outcome and Assessment Information Set (OASIS), as described in sections 484.55 and 484.250 of title 42, the Code of Federal Regulations, or any successor regulation, or any other instrument used with respect to home health agencies for such purposes; in the case of skilled nursing facilities, the resident’s assessment under section 1395i–3(b)(3) of this title ; in the case of inpatient rehabilitation facilities, any Medicare beneficiary assessment instrument established by the Secretary for purposes of section 1395ww(j) of this title ; and in the case of long-term care hospitals, the Medicare beneficiary assessment instrument used with respect to such hospitals for the collection of data elements necessary to calculate quality measures as described in the August 18, 2011 , Federal Register (76 Fed. Reg. 51754–51755), including for purposes of section 1395ww(m)(5)(C) of this title , or any other instrument used with respect to such hospitals for assessment purposes. for home health agencies, section 1395fff(b)(3)(B)(v) of this title ; for skilled nursing facilities, section 1395yy(e)(6) of this title ; for inpatient rehabilitation facilities, section 1395ww(j)(7) of this title ; and for long-term care hospitals, section 1395ww(m)(5) of this title . with respect to a home health agency, the prospective payment system under section 1395fff of this title ; with respect to a skilled nursing facility, the prospective payment system under section 1395yy(e) of this title ; with respect to an inpatient rehabilitation facility, the prospective payment system under section 1395ww(j) of this title ; and with respect to a long-term care hospital, the prospective payment system under section 1395ww(m) of this title . for PAC providers described in clauses (ii) and (iii) of paragraph (2)(A), October 1, 2016 ; for PAC providers described in clause (iv) of such paragraph, October 1, 2018 ; and for PAC providers described in clause (i) of such paragraph, January 1, 2019 ; for PAC providers described in clauses (ii), (iii), and (iv) of paragraph (2)(A), October 1, 2016 ; and for PAC providers described in clause (i) of such paragraph, January 1, 2017 ; for PAC providers described in clause (i) of such paragraph, January 1, 2017 ; and for PAC providers described in clauses (ii), (iii), and (iv) of such paragraph, October 1, 2018 ; for PAC providers described in clauses (ii), (iii), and (iv) of paragraph (2)(A), October 1, 2016 ; and for PAC providers described in clause (i) of such paragraph, January 1, 2019 ; and for PAC providers described in clauses (ii), (iii), and (iv) of paragraph (2)(A), October 1, 2018 ; and for PAC providers described in clause (i) of such paragraph, January 1, 2019 . for PAC providers described in clauses (ii), (iii), and (iv) of paragraph (2)(A), October 1, 2016 ; and for PAC providers described in clause (i) of such paragraph, January 1, 2017 . The term “Medicare beneficiary” means an individual entitled to benefits under part A or, as appropriate, enrolled for benefits under part B. Beginning not later than October 1, 2018 , for PAC providers described in clauses (ii), (iii), and (iv) of subsection (a)(2)(A) and January 1, 2019 , for PAC providers described in clause (i) of such subsection, the Secretary shall require PAC providers to submit to the Secretary, under the applicable reporting provisions and through the use of PAC assessment instruments, the standardized patient assessment data described in subparagraph (B). The Secretary shall require such data be submitted with respect to admission and discharge of an individual (and may be submitted more frequently as the Secretary deems appropriate). Functional status, such as mobility and self care at admission to a PAC provider and before discharge from a PAC provider. Cognitive function, such as ability to express ideas and to understand, and mental status, such as depression and dementia. Special services, treatments, and interventions, such as need for ventilator use, dialysis, chemotherapy, central line placement, and total parenteral nutrition. Medical conditions and co-morbidities, such as diabetes, congestive heart failure, and pressure ulcers. Impairments, such as incontinence and an impaired ability to hear, see, or swallow. Other categories deemed necessary and appropriate by the Secretary. To the extent practicable, not later than October 1, 2018 , for PAC providers described in clauses (ii), (iii), and (iv) of subsection (a)(2)(A), and January 1, 2019 , for PAC providers described in clause (i) of such subsection, the Secretary shall match claims data with assessment data pursuant to this section for purposes of assessing prior service use and concurrent service use, such as antecedent hospital or PAC provider use, and may use such matched data for such other uses as the Secretary determines appropriate. In the case of patient assessment data being used with respect to a PAC assessment instrument that duplicates or overlaps with standardized patient assessment data within a category described in paragraph (1), the Secretary shall, as soon as practicable, revise or replace such existing data with the standardized data. Standardized patient assessment data submitted pursuant to this subsection shall not be used to require individuals to be provided post-acute care by a specific type of PAC provider in order for such care to be eligible for payment under this subchapter. Functional status, cognitive function, and changes in function and cognitive function. Skin integrity and changes in skin integrity. Medication reconciliation. Incidence of major falls. from a hospital or critical access hospital to another applicable setting, including a PAC provider or the home of the individual; or from a PAC provider to another applicable setting, including a different PAC provider, a hospital, a critical access hospital, or the home of the individual. To the extent possible, the Secretary shall require such reporting by a PAC provider of quality measures under paragraph (1) through the use of a PAC assessment instrument and shall modify such PAC assessment instrument as necessary to enable the use of such instrument with respect to such quality measures. The Secretary may not make significant modifications to a PAC assessment instrument more than once per calendar year or fiscal year, as applicable, unless the Secretary publishes in the Federal Register a justification for such significant modification. The Secretary shall consider applying adjustments to the quality measures under this subsection taking into consideration the studies under section 2(d) of the IMPACT Act of 2014. Such quality measures shall be risk adjusted, as determined appropriate by the Secretary. Resource use measures, including total estimated Medicare spending per beneficiary. Discharge to community. Measures to reflect all-condition risk-adjusted potentially preventable hospital readmission rates. With respect to the period of time used for calculating measures under paragraph (1)(A), the Secretary shall, to the extent the Secretary determines appropriate, align resource use with the methodology used for purposes of section 1395ww( o )(2)(B)(ii) of this title. The Secretary shall standardize measures with respect to the domain described in paragraph (1)(A) for geographic payment rate differences and payment differentials (and other adjustments, as applicable) consistent with the methodology published in the Federal Register on August 18, 2011 (76 Fed. Reg. 51624 through 51626), or any subsequent modifications made to the methodology. The Secretary shall adjust, as appropriate, measures with respect to the domain described in paragraph (1)(A) for the factors applied under section 1395ww( o )(2)(B)(ii) of this title. The Secretary shall consider applying adjustments to the resource use and other measures specified under this subsection with respect to the domain described in paragraph (1)(A), taking into consideration the studies under section 2(d) of the IMPACT Act of 2014. Such resource use and other measures shall be risk adjusted, as determined appropriate by the Secretary. measure specification, including informing the public of the measure’s numerator, denominator, exclusions, and any other aspects the Secretary determines necessary; data collection, including, in the case of quality measures, requiring PAC providers to report data elements needed to calculate such a measure; and data analysis, including, in the case of resource use and other measures, the use of claims data to calculate such a measure. The second implementation phase, with respect to such a measure, shall consist of the provision of feedback reports to PAC providers, in accordance with subsection (f). The third implementation phase, with respect to such a measure, shall consist of public reporting of PAC providers’ performance on such measure in accordance with subsection (g). Subject to subparagraph (B), each measure specified by the Secretary under this section shall be endorsed by the entity with a contract under section 1395aaa(a) of this title . In the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical measure has not been endorsed by the entity with a contract under section 1395aaa(a) of this title , the Secretary may specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary. Subject to subparagraph (B), the provisions of section 1395aaa–1 of this title shall apply in the case of a quality measure specified under subsection (c) or a resource use or other measure specified under subsection (d). For purposes of satisfying subparagraph (A), the Secretary may use expedited procedures, such as ad-hoc reviews, as necessary, in the case of a quality measure specified under subsection (c) or a resource use or other measure specified in subsection (d) required with respect to data submissions under the applicable reporting provisions during the 1-year period before the specified application date applicable to such a measure and provider involved. The Secretary may waive the application of the provisions of section 1395aaa–1 of this title in the case of a quality measure or resource use or other measure described in clause (i), if the application of such provisions (including through the use of an expedited procedure described in such clause) would result in the inability of the Secretary to satisfy any deadline specified in this section with respect to such measure. Beginning one year after the specified application date, as applicable to PAC providers and quality measures and resource use and other measures under this section, the Secretary shall provide confidential feedback reports to such PAC providers on the performance of such providers with respect to such measures required under the applicable provisions. To the extent feasible, the Secretary shall provide feedback reports described in paragraph (1) not less frequently than on a quarterly basis. Notwithstanding the previous sentence, with respect to measures described in such paragraph that are reported on an annual basis, the Secretary may provide such feedback reports on an annual basis. Subject to the succeeding paragraphs of this subsection, the Secretary shall provide for public reporting of PAC provider performance on quality measures under subsection (c)(1) and the resource use and other measures under subsection (d)(1), including by establishing procedures for making available to the public information regarding the performance of individual PAC providers with respect to such measures. The procedures under paragraph (1) shall ensure, including through a process consistent with the process applied under section 1395ww(b)(3)(B)(viii)(VII) of this title for similar purposes, that a PAC provider has the opportunity to review and submit corrections to the data and information that is to be made public with respect to the provider prior to such data being made public. Such procedures shall provide that the data and information described in paragraph (1), with respect to a measure and PAC provider, is made publicly available beginning not later than two years after the specified application date applicable to such a measure and provider. In the case of home health agencies, section 1395fff(b)(3)(B)(v)(III) of this title . In the case of skilled nursing facilities, sections 1395i–3(i) and 1396r(i) of this title. In the case of inpatient rehabilitation facilities, section 1395ww(j)(7)(E) of this title . In the case of long-term care hospitals, section 1395ww(m)(5)(E) of this title . The Secretary may remove, suspend, or add a quality measure or resource use or other measure described in subsection (c)(1) or (d)(1), so long as, subject to paragraph (2), the Secretary publishes in the Federal Register (with a notice and comment period) a justification for such removal, suspension, or addition. In the case of such a quality measure or resource use or other measure for which there is a reason to believe that the continued collection of such measure raises potential safety concerns or would cause other unintended consequences, the Secretary may promptly suspend or remove such measure and satisfy paragraph (1) by publishing in the Federal Register a justification for such suspension or removal in the next rulemaking cycle following such suspension or removal. treatment preferences of patients; and goals of care of patients. All requirements applied pursuant to paragraph (1) shall be used to help inform and mandate the discharge planning process. Such regulations shall not require an individual to be provided post-acute care by a specific type of PAC provider in order for such care to be eligible for payment under this subchapter. Before the initial rulemaking process to implement this section, the Secretary shall allow for stakeholder input, such as through town halls, open door forums, and mail-box submissions. For purposes of carrying out this section, the Secretary shall provide for the transfer to the Centers for Medicare & Medicaid Services Program Management Account, from the Federal Hospital Insurance Trust Fund under section 1395i of this title and the Federal Supplementary Medical Insurance Trust Fund under section 1395t of this title , in such proportion as the Secretary determines appropriate, of $130,000,000. Fifty percent of such amount shall be available on October 6, 2014 , and fifty percent of such amount shall be equally proportioned for each of fiscal years 2015 through 2019. Such sums shall remain available until expended. There shall be no administrative or judicial review under sections 1395ff and 1395 oo of this title or otherwise of the specification of standardized patient assessment data required, the determination of measures, and the systems to report such standardized data under this section. Chapter 35 of title 44 (commonly referred to as the “Paperwork Reduction Act of 1995”) shall not apply to this section and the sections referenced in subsection (a)(2)(B) that require modification in order to achieve the standardization of patient assessment data. does not initially include skilled nursing care; includes occupational therapy; and includes physical therapy or speech language pathology.” The Secretary of Health and Human Services (in this subsection referred to as the ‘Secretary’) shall conduct a study that examines the effect of individuals’ socioeconomic status on quality measures and resource use and other measures for individuals under the Medicare program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq.) (such as to recognize that less healthy individuals may require more intensive interventions). The study shall use information collected on such individuals in carrying out such program, such as urban and rural location, eligibility for Medicaid under title XIX of such Act ( 42 U.S.C. 1396 et seq.) (recognizing and accounting for varying Medicaid eligibility across States), and eligibility for benefits under the supplemental security income (SSI) program. The Secretary shall carry out this paragraph acting through the Assistant Secretary for Planning and Evaluation. Not later than 2 years after the date of the enactment of this Act [ Oct. 6, 2014 ], the Secretary shall submit to Congress a report on the study conducted under clause (i). The Secretary shall conduct a study that examines the impact of risk factors, such as those described in section 1848(p)(3) of the Social Security Act ( 42 U.S.C. 1395w–4(p)(3) ), race, health literacy, limited English proficiency (LEP), and Medicare beneficiary activation, on quality measures and resource use and other measures under the Medicare program (such as to recognize that less healthy individuals may require more intensive interventions). In conducting such study the Secretary may use existing Federal data and collect such additional data as may be necessary to complete the study. Not later than 5 years after the date of the enactment of this Act, the Secretary shall submit to Congress a report on the study conducted under clause (i). In conducting the studies under subparagraphs (A) and (B), the Secretary shall examine what non-Medicare data sets, such as data from the American Community Survey (ACS), can be useful in conducting the types of studies under such paragraphs and how such data sets that are identified as useful can be coordinated with Medicare administrative data in order to improve the overall data set available to do such studies and for the administration of the Medicare program. obtain access to the necessary data (if such data is not already being collected) on such factors, including recommendations on how to address barriers to the Centers in accessing such data; and in quality measures, resource use measures, and other measures under title XVIII of the Social Security Act (including such measures specified under subsections (c) and (d) of section 1899B of such Act [ 42 U.S.C. 1395 lll ], as added by subsection (a)); and in determining payment adjustments based on such measures in other applicable provisions of such title. There are hereby appropriated to the Secretary from the Federal Hospital Insurance Trust Fund under section 1817 of the Social Security Act ( 42 U.S.C. 1395i ) and the Federal Supplementary Medical Insurance Trust Fund under section 1841 of such Act ( 42 U.S.C. 1395t ) (in proportions determined appropriate by the Secretary) to carry out this paragraph $6,000,000, to remain available until expended. assess appropriate adjustments to quality measures, resource use measures, and other measures under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq.) (including measures specified in subsections (c) and (d) of section 1899B of such Act, as added by subsection (a)); and assess and implement appropriate adjustments to payments under such title based on measures described in clause (i). The Secretary shall collect or otherwise obtain access to the data necessary to carry out this paragraph through existing and new data sources. The Secretary shall carry out periodic analyses, at least every 3 years, based on the factors referred to in subparagraph (A) so as to monitor changes in possible relationships. There are hereby appropriated to the Secretary from the Federal Hospital Insurance Trust Fund under section 1817 of the Social Security Act ( 42 U.S.C. 1395i ) and the Federal Supplementary Medical Insurance Trust Fund under section 1841 of such Act ( 42 U.S.C. 1395t ) (in proportions determined appropriate by the Secretary) to carry out this paragraph $10,000,000, to remain available until expended. Not later than 18 months after the date of the enactment of this Act [ Oct. 6, 2014 ], the Secretary shall develop and report to Congress on a strategic plan for collecting or otherwise accessing data on race and ethnicity for purposes of specifying quality measures and resource use and other measures under subsections (c) and (d) of section 1899B of the Social Security Act, as added by subsection (a), and, as the Secretary determines appropriate, other similar provisions of, including payment adjustments under, title XVIII of such Act ( 42 U.S.C. 1395 et seq.).”