prompt_front: You are given two reports by the government agency.



Question: Write a one-page summary of the report 1.



Report 2: Spinal cord injuries are complex, lifelong injuries that typically result from acute traumatic damage to the spinal cord or nerves within the spinal column  In spinal cord injury patients, certain nervous system functions may be impaired temporarily or permanently lost, depending on the level and severity of the patient’s injury  In addition to lower level nervous system functioning, spinal cord injury patients may develop secondary medical complications that can further decrease functional independence and quality of life, including, but not limited to: Autonomic dysreflexia: a condition that may result in life threatening hypertension—high blood pressure—due to impaired nervous system response, below the level of spinal cord injury  Depression: a medical mood disorder—commonly affecting about one in five spinal cord injury patients—that can cause physical and psychological symptoms (including changes in sleep and appetite, and thoughts of death or suicide)  Impaired bowel and bladder functioning: potential inability to move waste through the colon and control, stop or release, urine—which can lead to other life-threatening illnesses (such as autonomic dysreflexia) and/or infections  Pressure ulcers: a common complication affecting up to 80 percent of spinal cord injury patients that results from an area of the skin or underlying tissue that is damaged due to decreased blood flow, which can occur after extended periods of inactive sitting or lying, among other ways  Pressure ulcers—also known as pressure sores or wounds—can occur years after initial injury and may also result in life- threatening infections or amputation  Spasticity: a common condition that affects 65 to 78 percent of spinal cord injury patients and can result in symptoms ranging from mild muscle stiffness to severe, uncontrollable leg movements  Syringomyelia: a rare disorder that occurs when cerebrospinal fluid— normally found outside of the spinal cord and brain—enters the interior of the spinal cord to form a cyst known as a syrinx  This cyst expands and elongates over time, destroying the center of the spinal cord  Symptoms can develop slowly and can include numbness, pain, effects on bowel and bladder function, or paralysis  While this condition can occur as a result of a trauma, such as a spinal cord injury, the majority of cases are associated with a complex brain abnormality  Acquired brain injuries occur after birth and are not hereditary, congenital, degenerative, or a result of birth trauma  Acquired brain injuries result in changes to the brain’s neuronal activity, which can affect the physical integrity, metabolic activity, or functional ability of nerve cells in the brain  Acquired brain injuries can be either non-traumatic or traumatic in nature: non-traumatic brain injuries are caused by an internal force—such as in the case of stroke, tumors, or drowning—and traumatic brain injuries are caused by an external force—such as in the case of car accidents, gunshot wounds, or falls  The severity of brain injury can often result in changes to physical, behavioral, and/or cognitive functioning  For example, according to one source, nearly 50 percent of all people with a traumatic brain injury experience depression within the first year after injury, and nearly two-thirds experience depression within 7 years post- injury  Depression can develop as a result of physical changes in the brain, emotional response to the injury, and other unrelated factors—such as family history  Due to impaired cognitive functioning, traumatic brain injury patients may also experience difficulty communicating, concentrating, and processing and understanding information  Acute care hospitals and LTCHs are paid under different Medicare payment systems by law  Acute care hospitals are paid under the inpatient prospective payment system (IPPS)  LTCHs are paid under the LTCH PPS  Under both systems, Medicare classifies patients based on Medicare diagnosis groups, which organize patients based on their conditions and the care they receive  Medicare payments for LTCHs are typically higher than payments for acute care hospitals, to reflect the average resources required to treat Medicare beneficiaries who need long-term care  Traditionally, all LTCH discharges were paid at the LTCH PPS standard federal payment rate  The Pathway for SGR Reform Act of 2013 modified the LTCH PPS by establishing a two-tiered payment system— such that certain LTCH discharges continue to be paid at the standard rate and others are paid at a generally lower, site-neutral rate  In its March 2013 report, MedPAC described concerns regarding growth in the number of LTCHs and the extent to which some of their patients may otherwise be treated appropriately in less costly settings  To continue to be eligible for the standard rate, the discharge must generally have a preceding acute care hospital stay with either an intensive care unit stay of at least 3 days or an assigned diagnosis group based on the receipt of at least 96 hours of mechanical ventilation services in the LTCH, unless an exception applies  Discharges that do not qualify for the standard rate are to receive a blended site-neutral rate—equal to 50 percent of the site-neutral rate and 50 percent of the standard rate—for discharges in cost reporting periods beginning in fiscal years 2016 through 2019, and the full site-neutral rate for discharges in cost reporting periods beginning in fiscal year 2020  Beginning with cost reporting periods in fiscal year 2020, if fewer than half of an LTCH’s discharges meet the statutory requirements to be paid at the standard rate, the LTCH will no longer receive any payments at that rate for discharges in future cost reporting periods until eligibility for receiving payments under that rate is reinstated  Under this scenario, all discharges in succeeding cost reporting periods would be paid at the generally lower rate that an acute care hospital would receive for providing comparable care until eligibility for receiving payments at the standard rate is reinstated  According to officials from HHS, the department intends to establish a process for how hospitals would have their eligibility for receiving payments at the standard rate reinstated as part of the fiscal year 2020 rule-making cycle  Since the two qualifying hospitals are currently only excepted from the statutory two-tiered payment structure for cost reporting periods beginning during fiscal years 2018 and 2019, these two hospitals must also meet the statutory 50 percent threshold in fiscal year 2020 and beyond in order to receive the standard rate for any future discharges until reinstated  See table 1 for more information on Medicare’s LTCH PPS payment policies  Two LTCHs have qualified for the temporary exception to site-neutral payments, according to CMS officials  Craig Hospital is a private, not-for- profit facility that has specialized in medical treatment, research, and rehabilitation for patients with spinal cord and brain injury since 1956  Craig Hospital is classified as an LTCH for the purposes of Medicare payment, and is licensed as a general hospital by the state of Colorado— which does not have separate designations for LTCHs  Craig Hospital has been selected as one of 14 NIDILRR Spinal Cord Injury Model Systems and one of 16 Traumatic Brain Injury Model Systems and is accredited by the Joint Commission  Shepherd Center is a private, not-for-profit facility that specializes in medical treatment, research, and rehabilitation for people with traumatic spinal cord injury and brain injury—as well as neuromuscular disorders, including multiple sclerosis  Shepherd Center is classified as an LTCH for the purposes of Medicare payment, and as a specialty hospital—which includes LTCHs—by the state of Georgia  Shepherd Center is also currently designated as a NIDILRR Spinal Cord Injury Model System and is accredited by the Joint Commission  Shepherd Center also has several CARF International accredited specialty programs  Specifically, it has CARF-accredited inpatient rehabilitation specialty programs in spinal cord injury and brain injury—for adults, children, and adolescents; and interdisciplinary outpatient medical rehabilitation specialty programs in spinal cord injury and brain injury—for adults, children, and adolescents, among others  More than half of the Medicare discharges in fiscal year 2013 at the two qualifying hospitals—43 of 75 at Craig Hospital and 47 of 88 at Shepherd Center—were within the diagnosis groups designated in section 15009(a) of the 21st Century Cures Act  (See table 2 below for more information ) Patients treated for these diagnosis groups may receive treatment for spinal disorders and injuries; medical back problems; degenerative nervous system disorders; skin grafts for skin ulcers; acquired brain injuries, such as traumatic brain injuries; or other significant traumas with major complicating and comorbid (simultaneous) conditions  Both qualifying hospitals have a variety of specialized inpatient and outpatient programs to help treat the complex health care needs of their patients, including those covered by Medicare  For example, both hospitals have wheelchair positioning clinics that can help prevent skin complications, such as pressure ulcers, that can occur in spinal cord patients  Both hospitals also have programs for those patients who need ventilator support such as diaphragmatic pacing—support for patients with respiratory problems whose diaphragm, lungs, and nerves have limited function—and ventilator weaning programs  In addition to clinical programs, both qualifying hospitals also provide transitional support, such as providing counseling and education to families of patients with these injuries  We found that most Medicare beneficiaries at the two qualifying hospitals need specialized services to manage the chronic, long-term effects of a catastrophic spinal cord or brain injury  Most of these patients are younger than 65 and ineligible for Medicare at the time of their initial injury, according to officials from the qualifying hospitals  Instead, according to officials, these patients typically become eligible for Medicare 2 years or more after their initial injury due to disability  Medicare beneficiaries at the two qualifying hospitals typically need care to manage comorbidities or the associated long-term complications of their injury  Officials from Craig Hospital said a significant number of their Medicare beneficiaries have comorbid conditions—such as diabetes or cardiac problems—upon admission, that can be further complicated by their injury  The officials said managing these comorbidities is as much of a medical challenge as managing the spinal or brain injury  Officials from both qualifying hospitals noted their Medicare beneficiaries who have a spinal cord or brain injury also frequently seek care after initial injury to address secondary complications resulting from their injury, including urinary tract infections; respiratory problems; and pressure ulcers  While the qualifying hospitals primarily treated traumatic spinal cord or brain injuries, we found that their Medicare populations differed from each other during the period from fiscal year 2013 to 2016  Specifically, Craig Hospital  Our review of Medicare claims data indicates more than 50 percent of the 246 Medicare discharges during this time were associated with Medicare diagnosis groups for spinal cord conditions  Specifically, during this time, Craig Hospital’s Medicare discharges were commonly assigned to three diagnosis groups covering spinal procedures and spinal disorders and injuries  For example, officials from Craig Hospital told us that about 60 percent of Medicare beneficiaries in fiscal year 2016 required surgical care for a spinal cord injury  According to officials, most of these patients received surgery for syringomyelia—a complication in spinal cord patients that generally develops years after their initial injury  These officials told us that Craig Hospital provided the pre- and post-operative care for those patients in fiscal year 2016; however, currently, Craig Hospital is only responsible for pre-operative assessments  The remaining 40 percent of their Medicare beneficiaries in fiscal year 2016 received care for new spinal cord injuries  Shepherd Center  Our review of Medicare claims data indicates the most common diagnosis group of the 365 Medicare discharges during this time—fiscal year 2013 to fiscal year 2016—related to treatment for skin grafts that can be associated with pressure ulcers, among other things  Shepherd Center officials confirmed that most of their Medicare beneficiaries received treatment for a pressure ulcer that occurred after initial injury which, as previously noted, can be so severe as to result in life-threatening infections  According to officials, most of their post-injury Medicare beneficiaries receive post-operative care and other wound management services following surgery to treat pressure ulcers, to ensure that the site will not tear again and to avoid reoccurrence  Other diagnosis groups for Medicare patients at Shepherd Center included those for spinal disorders and injuries and extensive operating room procedures unrelated to principal diagnosis  According to officials, beneficiaries in these diagnosis groups received treatment for a range of conditions, including traumatic injuries, urinary tract infections, neurogenic bladder and bowel or respiratory complications  Officials told us the hospital also served Medicare beneficiaries recovering from other acquired brain injuries, such as stroke, and paralyzing neuromuscular conditions, such as multiple sclerosis  Stakeholders we interviewed—including providers at other facilities— noted that traumatic spinal cord and brain injury patients—including those covered by Medicare—require significant levels of care due to the complexity of their injuries as well as the immediate and long-term complications that can occur from the injuries  For example, most stakeholders told us these patients often require lifelong care due to the complexity and reoccurrence of comorbidities or secondary complications  Some of these stakeholders noted, for example, spinal cord and brain injury patients often face mental health or psychosocial conditions, such as depression or anxiety  Some stakeholders also emphasized that many spinal cord injury patients risk secondary complications that may not occur until years after injury, such as pneumonia, pressure ulcers, and other infections  A few stakeholders told us spinal cord and brain injury patients are often among the most complex patients they treat  As such, patients with spinal cord or brain injuries often require interdisciplinary care that covers a wide range of specialties—including physiatry (rehabilitation medicine), neurology, cardiology, and pulmonology—as well as specialized equipment or technology, such as eye glance tools to control call systems or the television  Simulations of Medicare payments illustrate the potential effects of Medicare’s site-neutral payment policies, which were required by law, on the qualifying hospitals  Specifically, our simulations calculated what the qualifying hospitals would have been paid for Medicare patient discharges that occurred in two baseline years—fiscal year 2013 (baseline year 1) and fiscal year 2016 (baseline year 2)—if applicable payment policies from future years (2017 through 2021) were applied to those discharges  We selected two baseline years to account for differences in data, such as the number of discharges, between fiscal year 2016—the most recent year of complete data available at the time we began our analysis—and fiscal year 2013  Table 3 below provides a summary of Medicare discharges and payments to the qualifying hospitals during these two baseline years  Variation in utilization and patient mix across the baseline years allows the simulations to cover a range of possible changes in payments for the two hospitals  Our simulations indicated how Medicare’s payment policies could have affected these baseline payments to each qualifying hospital: Fiscal Year 2017 Blended Site-Neutral Rate Policy: Discharges that do not meet criteria to receive the standard rate are to receive a blended site-neutral rate—equal to 50 percent of the site-neutral rate and 50 percent of the standard rate  We found that while some of the baseline discharges would qualify for the standard rate, most discharges would have been paid at the blended site-neutral rate  Specifically, 8 to 20 percent of Craig Hospital’s baseline Medicare discharges would have qualified for the standard rate, resulting in simulated payments of about $3 86 million (baseline year 1) and $3 22 million (baseline year 2) under blended site-neutral rate policy  For Shepherd Center, between 23 percent and 40 percent of baseline Medicare discharges would have qualified for the standard rate, resulting in simulated payments of about $5 16 million (baseline year 1) and $5 31 million (baseline year 2)  Each of these simulated payments is an increase compared to actual payments made in the baseline years  Fiscal Years 2018 and 2019 Temporary Exception: The qualifying hospitals are receiving the standard rate for all discharges, due to the temporary exception  As a result, simulated payments under the temporary exception are about $3 74 million (baseline year 1) and $3 18 million (baseline year 2) for Craig Hospital and about $5 64 million (baseline year 1) and $5 75 million (baseline year 2) for Shepherd Center, which is an increase compared to actual payments made in the baseline years  Fiscal Year 2020 Two-Tiered Payment Rate: The temporary exception for the qualifying hospitals no longer applies; therefore, the site- neutral rate will apply to discharges not qualifying for the standard rate  We found that both qualifying hospitals would receive some payments at the standard rate, but that most of their discharges would be paid at the lower, site-neutral rate—assuming similar caseloads (e g , patient mix)  As a result, simulated baseline year payments at Craig Hospital are about $3 47 million (baseline year 1) and $3 03 million (baseline year 2), and simulated baseline payments to Shepherd are about $4 42 million (baseline year 1) and $4 55 million (baseline year 2)  The simulated payments therefore decrease compared to those in fiscal year 2019, and also generally decrease compared to actual payments made in the baseline years  Future Years Under 50 Percent Threshold: Under statute, unless 50 percent or more of the hospital’s discharges in cost reporting periods beginning during or after fiscal year 2020 qualify for the standard rate, no subsequent payments will be made to a hospital at that rate in each succeeding cost reporting period  Most of the baseline year discharges did not qualify for the standard rate, and therefore simulated payments are based on the generally lower comparable acute care rate  However, simulated payments stayed about the same between fiscal year 2020 and 2021, in part due to differences in calculations for high-cost outlier payments  A high-cost outlier payment is made to hospitals for those cases that are extraordinarily costly, which can occur because of the severity of the case and/or a particularly long length of stay  Specifically, simulated payments were about $3 49 million (baseline year 1) and $3 02 million (baseline year 2) for Craig Hospital and about $4 24 million (baseline year 1) and $4 16 million (baseline year 2) for Shepherd Center  Without the high-cost outlier payments, the simulated payments would have decreased by at least $2 million  If the mix of patients at Craig Hospital and Shepherd Center changes so that they meet the 50 percent threshold in fiscal year 2020, then simulated payments for fiscal year 2021 could be higher  As of September 2018, Craig Hospital officials told us that they expect to meet the 50 percent threshold with their current patient mix  Shepherd Center officials told us they do not expect to meet the 50 percent threshold  See figures 1 and 2 below for the results of our simulations  Our simulations of payments assume the number and type of Medicare discharges at the two qualifying hospitals remain the same as those in fiscal years 2013 and 2016  However, the full effect of payment policy on future Medicare payments to the qualifying hospitals will depend on three key factors that are subject to change: 1  Severity of patient conditions: Medicare payment is typically higher for more severe injuries, such as a traumatic injury with major comorbidities or complications, relative to less severe injuries  In the two baseline years we used for our simulations—fiscal year 2013 and fiscal year 2016—more than half of the Medicare discharges at the qualifying hospitals were associated with conditions with multiple comorbidities and complications, as indicated by the diagnosis groups, and this level of severity is reflected in the simulation results  Future payments to qualifying hospitals will depend on the extent to which the severity of patient conditions changes over time  2  Volume of discharges meeting criteria for the standard rate: As previously noted, for a hospital to receive the standard rate for a discharge, the discharge must meet certain criteria, such as having a preceding acute care hospital stay with either an intensive care unit stay of at least 3 days or an assigned diagnosis group based on the receipt of at least 96 hours of mechanical ventilation services in the LTCH  Our simulations reflect that in the two baseline years, about 23 percent of the fiscal year 2013 discharges and about 40 percent of the fiscal year 2016 discharges met the criteria to receive the standard rate for Shepherd Center; and about 8 percent of the fiscal year 2013 discharges and about 20 percent of the fiscal year 2016 discharges met the criteria for Craig Hospital  Changes to these amounts could affect future payments to the qualifying hospitals  In particular, if 50 percent or more of either hospital’s discharges beginning in fiscal year 2020 meet the standard rate criteria, then the hospitals would be eligible for payments at the standard rate in fiscal year 2021, which may result in higher payments compared to our simulations  3  Payment adjustments: LTCHs may receive a payment adjustment for certain types of discharges, such as short-stay outliers, interrupted stays, or high-cost outliers  In particular, most discharges at Craig Hospital received high-cost outlier payments (additional payments for extraordinarily costly cases) during the two baseline years—76 percent in fiscal year 2013 and 85 percent in fiscal year 2016  At Shepherd Center, at least 40 percent of discharges during the two baseline years received high-cost outlier payments—about 42 percent in fiscal year 2013 and about 58 percent in fiscal year 2016  The amount of future payments to qualifying hospitals will depend on the extent to which they continue to have a high proportion of discharges with high-cost outlier payments  In addition to the effect on payments, officials from both qualifying hospitals and some stakeholders we interviewed noted that the LTCH site-neutral payment policies may result in fewer services provided and fewer patients served by the qualifying hospitals and other LTCHs  For example, officials from Craig Hospital told us they stopped providing post- operative care to patients requiring spinal surgery, such as patients with syringomyelia, in 2016—instead referring them to other facilities—in part because these discharges do not meet the criteria for the standard rate  As of September 2018, they told us they do not plan to provide this care in the future unless the temporary exception is extended  Officials from Shepherd Center told us while they have not yet made changes to services they offer to Medicare patients, they may limit which Medicare beneficiaries they serve in the future  For example, they told us that most of their Medicare beneficiaries were admitted from home or sought care in their outpatient clinic  When the temporary exception expires after fiscal year 2019, hospital officials expected that these patients will not qualify for the standard rate  Shepherd Center officials said they may not be able to serve similar patients in future years  MedPAC officials and some stakeholders—a specialty association and health care providers with experience treating patients with similar conditions at other LTCHs—told us that some LTCHs have changed the services they offer and the patients they treat to increase the proportion of discharges that qualify for the standard rate  For example, MedPAC officials cited reports that indicate how some LTCHs have adjusted to the site-neutral policies  For example, a 2018 MedPAC report indicated that LTCHs in one large for-profit chain were able to make adjustments so that, as of September 30, 2016, close to 100 percent of their Medicare discharges met the criteria to receive the standard rate  A representative from an LTCH association told us that many LTCHs have adjusted their patient mix by increasing the number of discharges that meet criteria for the standard rate and turning away some Medicare beneficiaries to reduce the number of discharges subject to the site-neutral rate  The representative noted that certain LTCHs have already been able to adjust their patient mix because they have existing programs in place that focus on chronic, critically ill patients who would have a preceding acute care hospital stay  The representative told us that some LTCHs specialize in care for patients who do not meet the criteria to receive the standard rate and would generally be paid at the site-neutral rate; therefore, changing their patient mix is not a viable strategy for these LTCHs  According to the stakeholder, as of February 2018, about two-thirds of all LTCHs are above the 50 percent threshold  Providers from another LTCH told us that before the site-neutral payment policy went into effect, only about 40 to 45 percent of its discharges met criteria for the standard rate  However, they worked to ensure most patients referred to the LTCH would qualify for the standard rate  Officials told us patients who do not meet the criteria for that rate typically either stay longer in the acute care hospital or are transferred to a different post-acute care setting, such as a skilled nursing facility  Officials noted that, in both cases, the patient may not receive the specialized services often required for their injuries, including those patients with spinal cord or brain injuries  A provider we interviewed from another LTCH said that, historically, the LTCH has accepted patients who acquire pressure ulcers at home following discharge, but they may choose not to continue this practice because the patients’ discharges would not meet the criteria to receive the standard rate  A few of these stakeholders told us some LTCHs are in markets that do not have alternative providers of care, such as skilled nursing facilities, for patients who do not meet the criteria  These LTCHs may have difficulty adjusting their patient mix to avoid site-neutral payments  For example, a provider from one LTCH said his facility continues to take “site-neutral patients” because those patients often do not have another option to receive the specialized services they need
Report 2:  787 (115 th Congress) which provided that "Section 3(a) of House Resolution 5 is amended by striking 'the first session of '" This separate order was not adopted for the 116 th Congress, so the application of the rule reverts to being guided by prior precedents rather than this language  Since the period immediately after the initial adoption of the rule in the 19 th century, the House has interpreted it through precedents that have tended to incrementally narrow its application  For example, early precedents established that while it was not always necessary that a retrenchment specify the amount of a reduction of expenditures, it must appear as a necessary result of the legislation to be in order and that it is not sufficient that such reduction would probably (or would in the opinion of the chair) result therefrom  For example, legislation that would simply confer discretionary authority to terminate employment of federal employees is not in order under the Holman exception because any resulting savings would be speculative  The reduction also may not be contingent on an event  Furthermore, the rule is not applicable to funds other than those appropriated in the pending general appropriations bill  The Holman rule then is intended to apply only when an obvious reduction of funds in a general appropriations bill is achieved by the provision in question, such as the cessation of specific government activities, or through a specific reduction of total appropriations in the bill  In addition, the exception does not apply to limitations (on the grounds that such language is not legislative) or legislative language unaccompanied by a reduction of funds in the bill  Legislation that is too broad has also typically not been allowed under the Holman rule exception  The House has held, for example, that a provision that stated no part of an appropriation could be expended for a specific, designated purpose qualified as a retrenchment  However, a proposal that effectively repealed the law under which appropriations for that purpose were authorized was held not to come within the exception  In another case, the House held that even when a provision does reduce expenditures, it may not be accompanied by additional legislative provisions not directly contributing to the reduction  The separate order for the 115 th Congress effectively reinstated language that had been stricken from the rule in 1983  While the full scope of amendments might be in order as a consequence of this language, it is possible to analyze its potential impact based on past precedents and the limited experience of the 115 th Congress  The additional language opened the door to the consideration of retrenchments resulting from a reduction of the number and salary of the officers of the United States or the reduction of the compensation of any person paid out of the Treasury of the United States  There are precedents regarding provisions allowed under the older, pre-1983 form of the rule that may be illustrative for understanding what might be in order  For example, a proposal that pay for a class of employees be limited to a smaller number of employees than authorized by law was allowed, as were proposals that would reduce the number of officers  The Holman rule also allowed proposals that would consolidate or eliminate offices  On at least one occasion, the Holman rule was the basis for allowing a proposal to replace civilian employees with lower paid U S  Army enlisted personnel  In another case, the rule allowed for an amendment that capped the salaries of certain employees  In the 115 th Congress, one amendment was considered in order based on a plain reading of the text of the separate order to allow for "the reduction of the compensation of any person paid out of the Treasury of the United States " Although the amendment failed of passage, it would have provided that: The salary of Mark Gabriel, the Administrator of the Western Area Power Administration, shall be reduced to $1  As cited above, however, neither the rule nor the separate order allows for retrenchments that would be applicable to funds other than those appropriated in the pending general appropriations bill  In addition, the application of the broader exceptions in the separate order were still subject to the general requirement for germaneness  The Holman rule is not intended to open the door for legislative provisions that would expand the scope of the bill  As a consequence, even with the additional scope provided by the language of the separate order, it would likely not be in order to include broad legislative provisions in, or amendments to, a specific appropriation bill that would apply to the salary or number of federal employees funded through appropriations in other measures  Furthermore, House precedent establishes that simply providing for a reduction of the number and salaries of officers in a paragraph when it is complicated by other elements does not necessarily bring a proposition within the exception  The Holman rule was also cited as the basis for allowing the consideration of one additional amendment during the 115 th Congress  That amendment also failed to pass, but it would have abolished the Budget Analysis Division of the Congressional Budget Office, comprising 89 employees with annual salaries aggregating $15 million, transferring responsibility for any duties imposed by law and regulation to the Office of the Director of the Congressional Budget Office  When discussing the application of rules and precedents, it is important to note that the House Parliamentarian is the sole definitive authority on questions relating to the chamber's precedents and procedures and should be consulted if a formal opinion on any specific parliamentary question is desired 

ground_truth: This report is designed to assist Members of Congress and their staff as they address the needs of their states, communities, and constituents after a disaster. It includes a summary of federal programs that provide federal disaster assistance to individual survivors, states, territories, local governments, and nongovernmental entities following a natural or man-made disaster. A number of federal agencies provide financial assistance through grants, loans, and loan guarantees to assist in the provision of critical services, such as temporary housing, counseling, and infrastructure repair. The programs summarized in this report fall into two broad categories. First, there are programs specifically authorized for use during situations occurring because of a disaster. Most of these programs are administered by the Federal Emergency Management Agency (FEMA). Second are general assistance programs that in some instances may be used either in disaster situations or to meet other needs unrelated to a disaster. Many federal agencies, including the Departments of Health and Human Services (HHS) and Housing and Urban Development (HUD), administer programs that may be included in the second category. The programs in the report are primarily organized by recipient: individuals, state and local governments, nongovernmental entities, or businesses. These programs address a variety of short-term needs, such as food and shelter, and long-term needs, such as the repair of public utilities and public infrastructure. The report also includes a list of Congressional Research Service (CRS) reports on disaster assistance as well as relevant federal agency websites that provide information on disaster responses, updates on recovery efforts, and resources on federal assistance programs. This report will be updated as significant legislative or administrative changes occur.

prompt_front: You are given two reports by the government agency.



Question: Write a one-page summary of the report 2.

Report 1: Federal agencies provide a range of assistance to individual survivors; state, territorial, and local governments; and nongovernmental entities after major disasters, including natural disasters and terrorist attacks  Types of aid can include, but are not limited to, operational, logistical, and technical support; financial assistance through grants, loans, and loan guarantees; and the provision of federally owned equipment and facilities  Many, but not all, programs are available after the President issues a major disaster declaration pursuant to the Robert T  Stafford Disaster Relief and Emergency Assistance Act (Stafford Act) authority  More limited aid is available under a Stafford Act emergency declaration, a declaration issued by a department or agency head, or on an as needed basis  This report only identifies programs frequently used to provide financial assistance in the disaster response and recovery process  It provides brief descriptive information to help congressional offices determine which programs merit further consideration in the planning, organization, or execution of the disaster response and recovery process  Most of the programs listed here are authorized as assistance programs and are listed at the General Services Administration (GSA) website beta SAM gov  The list does not include operational or technical assistance that some agencies provide in emergency or disaster situations  It is also not inclusive of all forms of financial disaster assistance that may be available to every jurisdiction in every circumstance, as unique factors often trigger unique forms of assistance  Congress may, and frequently has, authorized specific forms of financial assistance on a limited basis following particular disasters  Programs discussed in this report satisfy one or more of the following criteria: Congress expressly designated the program to provide financial assistance for disaster relief or recovery  The program is applicable to most disaster situations, even if not specifically authorized for that purpose  The Federal Emergency Management Agency (FEMA) and other federal agencies have frequently used the program to provide financial assistance  The program is potentially useful for addressing short-term and long-term recovery needs (e g , assistance with processing survivor benefits or repair of public facilities)  Most of the programs listed in this report are specifically authorized for use during situations occurring because of a disaster  General assistance programs that may apply to disaster situations are described at the end of the report (see " General Assistance Programs ")  As Congress and the Administration respond to domestic needs arising from major disasters, some conditions of these programs may be changed  For the most up-to-date information on a particular program, please contact the CRS analyst or department or agency program officers listed in the report  The Individuals and Households Program (IHP) is the primary vehicle for FEMA assistance to individuals and households after the President issues an emergency or major disaster declaration, when authorized  It is intended to meet basic needs and support recovery efforts, but it cannot compensate disaster survivors for all losses  Congress appropriates money for the IHP (and most other aid authorized by the Stafford Act) to the Disaster Relief Fund  IHP assistance is available in the form of financial and direct assistance to eligible individuals and households who, as a result of a disaster, have uninsured or under-insured necessary expenses and serious needs that cannot be met through other means or forms of assistance  Program funds have a wide range of eligible uses, including different forms of temporary housing assistance; housing repairs; housing replacement; and permanent housing construction  IHP funds may also be used for other needs assistance (ONA), including funeral, medical, dental, childcare, personal property, transportation, and other expenses  FEMA provides 100% of the housing assistance costs, but ONA is subject to a 75% federal and 25% state cost share  In addition, there is a limitation on the amount of financial assistance an individual or household may receive, with financial assistance including assistance to reimburse temporary lodging expenses; rent for alternate housing accommodations; home repairs and replacement; as well as ONA  Financial assistance for repairs and replacement may not exceed $34,900 (FY2019)  Separately, financial assistance for ONA may not exceed $34,900 (FY2019)  Financial assistance to rent alternate housing accommodations under Section 408 (c)(1)(A)(i) of the Stafford Act, however, is excluded from the cap  The maximum amount of financial assistance is adjusted annually to reflect changes in the Consumer Price Index  IHP assistance is intended to be temporary and is generally limited to a period of 18 months from the date of the declaration, but may be extended by FEMA  (Also see " Physical Disaster Loans—Residential SBA Disaster Loans Available to Homeowners and Renters " below for additional assistance for homeowners and renters ) Agency : Federal Emergency Management Agency Authority : 42 U S C  §5174 Regulation : 44 C F R  §§206 110–206 120 Phone : Office of Congressional Affairs, 202-646-4500 Website : https://www fema gov/media-library/assets/documents/24945 CFDA Program Numbers : 97 048 and 97 050 CRS Contact : Elizabeth Webster, 202-707-9197 Disaster Unemployment Assistance (DUA) provides benefits to previously employed or self-employed individuals rendered jobless as a direct result of a major disaster and who are not eligible for regular federal or state unemployment compensation (UC)  In certain cases, individuals who have no work history or are unable to work may also be eligible for DUA benefits  DUA is federally funded through FEMA, but is administered by the Department of Labor and state UC agencies  In general, individuals must apply for benefits within 30 days after the date the state announces availability of DUA benefits  When applicants have good cause, they may file claims after the 30-day deadline  This deadline may be extended; however, initial applications filed after the 26 th week following the declaration date will not be considered  When a reasonable comparative earnings history can be constructed, DUA benefits are determined in a similar manner to regular state UC benefit rules  The minimum weekly DUA benefit is required to be half of the average weekly UC benefit for the state where the disaster occurred  DUA assistance is available to eligible individuals as long as the major disaster continues, but no longer than 26 weeks after the disaster declaration  For more information, see CRS Report RS22022, Disaster Unemployment Assistance (DUA) , by Julie M  Whittaker  Agency: Department of Labor, Employment and Training Administration Authority: 42 U S C  §5177 Regulation: 20 C F R  §625; 44 C F R  §206 141 Contact: See listings of resources by state , https://www careeronestop org/localhelp/unemploymentbenefits/unemployment-benefits aspx Website: http://ows doleta gov/unemploy/disaster asp CFDA Program Number : 97 034 CRS Contact: Julie Whittaker, 202-707-2587 The dislocated worker program helps fund training and related assistance to persons who have lost their jobs and are unlikely to return to their current jobs or industries  Of the funds appropriated, 80% are allotted by formula grants to states and local entities and 20% are reserved by the Secretary of Labor to fund a national reserve that supports national dislocated worker grants to states or local ent ities  One type of national emergency grant is Disaster Relief Employment Assistance, under which funds can be made available to states to employ dislocated workers in temporary jobs involving recovery after a national emergency  An individual may be employed for up to 12 months  There are no matching requirements for Workforce Innovation and Opportunity Act (WIOA) programs  Agency: Department of Labor, Employment and Training Administration Authority: 29 U S C  §3225 Regulation: 20 C F R  §671 Contact: See listings of state Dislocated Worker/Rapid Response Coordinators at http://www doleta gov/layoff/rapid_coord cfm Website: https://www doleta gov/DWGs/eta_default cfm CFDA Program Number : 17 278 CRS Contact: David H  Bradley, 202-707-7352 The majority of disaster loans provided by the Small Business Administration (SBA), approximately 80%, are made available to individuals and households  SBA disaster assistance is provided in the form of loans, not grants, and therefore must be repaid to the federal government  Homeowners, renters, and personal property owners located in a declared disaster area (and in contiguous counties) may apply to the SBA for loans to help recover losses from the disaster  SBA's Home Disaster Loan Program falls into two categories: personal property loans and real property loans  These loans cover only uninsured or underinsured property and primary residences  Loan maturities may be up to 30 years  A personal property loan provides a creditworthy homeowner or renter with up to $40,000 to repair or replace personal property items, such as furniture, clothing, or automobiles, damaged or lost in a disaster  These loans cover only uninsured or underinsured property and primary residences and cannot be used to replace extraordinarily expensive or irreplaceable items, such as antiques, recreational vehicles, or furs  A creditworthy homeowner may apply for a "real property loan" of up to $200,000 to repair or restore the homeowner's primary residence to its predisaster condition  The loans may not be used to upgrade homes or build additions, unless upgrades or changes are required by city or county building codes  A real property loan may be increased by 20% for repairs to protect the damaged property from a similar disaster in the future  Agency: Small Business Administration Authority: 15 U S C  §636(b) Regulation: 13 C F R  §§123 200–123 204 Contact : Office of Congressional and Legislative Affairs, 202-205-6700 Website : https://disasterloan sba gov/ela/Information/TypesOfLoans CFDA Program Number : 59 008 CRS Contact : Bruce R  Lindsay, 202-707-3752 This unique fund directs payments to individuals and groups for disaster-related needs that have not been or will not be met by government agencies or other organizations  A disaster survivor will normally receive no more than $2,000 from this fund in any one declared disaster unless the Assistant Administrator for the Disaster Assistance Directorate determines that a larger amount is in the best interest of the disaster victim and the federal government  There is no matching requirement for this program and no limitation on the time period in which assistance is available  Agency: Federal Emergency Management Agency Authority: 42 U S C  §5121 et seq  Regulation: 44 C F R  §206 181 Contact : Office of Congressional Affairs, 202-646-4500 Website : http://www fema gov/library/viewRecord do?id=5037 CRS Contact: Bruce R  Lindsay, 202-707-3752 This program provides grants that enable states to offer crisis counseling services, when required, to victims of a federally declared major disaster for the purpose of relieving mental health problems caused or aggravated by the disaster or its aftermath  Assistance is short-term and community-oriented  Cost-share requirements are not imposed on this assistance  The regulations specify that program funding generally ends after nine months, but time extensions may be approved if requested by the state and approved by federal officials  Agency: Federal Emergency Management Agency Authority: 42 U S C  §5183 Regulation: 44 C F R  §206 171 Contact : Office of Congressional Affairs, 202-646-4500 Website: https://www fema gov/recovery-directorate/crisis-counseling-assistance-training-program CFDA Pr ogram Number : 97 032 CRS Contact: Sarah A  Lister, 202-707-7320 Disaster Legal Services (DLS) are provided for free to low-income individuals who require them as a result of a major disaster, and the provision of services is "confined to the securing of benefits under the [Stafford] Act and claims arising out of a major disaster " Assistance may include help with insurance claims, drawing up new wills and other legal documents lost in the disaster, help with home repair contracts and contractors, and appeals of FEMA decisions  Neither the statute nor the regulations establish cost-share requirements or time limitations for DLS  Agency: Federal Emergency Management Agency Authority: 42 U S C  §5182 Regulation: 44 C F R  §206 164 Contact : Office of Congressional Affairs, 202-646-4500 Website: https://www fema gov/media-library/assets/documents/24413 CFDA Program Number : 97 033 CRS Contact: Elizabeth Webster, 202-707-9197 The Disaster Case Management (DCM) program partners case managers and disaster survivors to develop and implement Disaster Recovery Plans to address unmet needs  The DCM program is authorized under the Stafford Act  Following a presidentially declared major disaster that includes Individual Assistance (IA), the governor or tribal executive may request a grant to use DCM providers to supply services to survivors with long-term, disaster-caused unmet needs  The program is time-limited, and it shall not exceed 24 months from the date of the presidential major disaster declaration  Agency: Federal Emergency Management Agency Authority: 42 U S C  §5189d Contact: Office of Congressional Affairs, 202-646-4500 Website: https://www fema gov/media-library/assets/documents/101292 CFDA Program Number : 97 088 CRS Contact: Elizabeth Webster, 202-707-9197 The Internal Revenue Code (IRC) includes tax relief provisions that apply to individuals and businesses affected by federally declared disasters, and the following are some examples  Individuals located in affected areas are allowed extra time (four years instead of the general two) to replace homes due to involuntary conversion (e g , destruction from wind or floods, theft, or property ordered to be demolished) and still defer any gain  Taxpayers may also be able to deduct personal casualty losses attributable to federally declared disasters, subject to certain limitations  Qualifying disaster relief payments received by affected individuals are not subject to tax  The Internal Revenue Service also has the authority to provide some relief, including the extension of tax filing deadlines  In addition to these and other permanent tax relief provisions, special temporary provisions have been enacted for certain disasters  The 2017 tax revision ( P L  115-97 ) provided tax relief related to 2016 and 2017 disasters  These measures were expanded to cover the California wildfires in the Bipartisan Budget Act of 2018 ( P L  115-123 )  Agency : Internal Revenue Service Authority : Various provisions throughout the Internal Revenue Code, Title 26 U S C , including §§123, 139, 165, 402, 408, 1033, 6654, 7508A Regulation : No specific regulation Contact : Congressional Liaison, 202-317-6985 Website : http://www irs gov/uac/Tax-Relief-in-Disaster-Situations CRS Contact s : Molly Sherlock, 202-707-7797 Authorized by multiple sections of the Stafford Act, the Public Assistance (PA) Grant Program is FEMA's primary form of financial assistance for state and local governments  The PA Program provides grant assistance for many eligible purposes, including the following: Emergency work, as authorized by Sections 403, 407, and 502 of the Stafford Act, which provide for the removal of debris and emergency protective measures, such as the establishment of temporary shelters and emergency power generation  Permanent work, as authorized by Section 406, which provides for the repair, replacement, or restoration of disaster-damaged, publicly owned facilities and the facilities of certain private nonprofit organizations (PNPs)  At its discretion, FEMA may provide assistance for hazard mitigation measures that are not required by applicable codes and standards  As a condition of PA assistance, applicants must obtain and maintain insurance on their facilities for similar future disasters  Management costs, as authorized by Section 324, which reimburses some of the applicant's administrative expenses incurred managing the totality of the PA Program's projects and grants  PNPs are generally eligible for permanent work assistance if they provide a governmental type of service, though PNPs not providing a "critical" service must first apply to the SBA for loan assistance for facility projects  The federal government provides a minimum of 75% of the cost of eligible assistance, and this cost share can rise if certain criteria are met  Funding for the PA Program comes through discretionary appropriations to the Disaster Relief Fund  Agency: Federal Emergency Management Agency Authority: 42 U S C  §§5170b, 5172, 5173, 5189f, 5192 Regulation: 44 C F R  §206, subparts G, H, I Contact : Office of Congressional Affairs, 202-646-4500 Website: http://www fema gov/public-assistance-local-state-tribal-and-non-profit CFDA Program Number : 97 036 CRS Contact: Natalie Keegan, 202-707-9569 The Hazard Mitigation Grant Program (HMGP) provides grants to states for implementing mitigation measures after a disaster and to provide funding for previously identified mitigation measures to lessen future damage and loss of life  The federal government provides up to 75% of the cost share of eligible projects  Historically, the amount available for HMGP awards is established by a scale that authorizes three tiers of awards: 15% of the total of other Stafford Act assistance in a state for a major disaster in which no more than $2 billion is provided; 10% for assistance that ranges from more than $2 billion to $10 billion; and 7 5% for a major disaster that involves Stafford Act assistance from more than $10 billion to $35 3 billion  Funding for HMGP comes through discretionary appropriations to the Disaster Relief Fund  The amount of funding provided can be increased if the state has an approved enhanced mitigation plan  HMGP funding is only awarded with a major disaster declaration, not an emergency declaration  However, during FY2015, FY2017, and FY2018, Congress directed that HMGP grants be made available with fire management assistance grants  Agency: Federal Emergency Management Agency Authority: 42 U S C  §5170c Regulation: 44 C F R  §§206 430–206 440 Contact : Office of Congressional Affairs , 202-646-4500 Website : http://www fema gov/hazard-mitigation-grant-program CFDA Program Number : 97 039 CRS Contact: Diane P  Horn, 202-707-3472 The Pre-Disaster Mitigation (PDM) Grant Program provides grants and technical assistance to states, territories, and local communities for cost-effective hazard mitigation activities that complement a comprehensive hazard mitigation program and reduce injuries, loss of life, and damage and destruction of property  Through FY2018, a minimum of the lesser of $575,000 or 1 0% of appropriated funds was provided to a state or local government, with assistance capped at 15% of appropriated funds  Federal funds generally comprise 75% of the cost of approved mitigation projects, except for small impoverished communities that may receive up to 90% of the cost  Funding for the PDM Program changed significantly with the passage of the Disaster Recovery Reform Act of 2018 (DRRA)  DRRA authorizes the National Public Infrastructure Pre-Disaster Mitigation Fund, for which the President may set aside from the DRF, with respect to each major disaster, an amount equal to 6% of the estimated aggregate amount of the grants to be made pursuant to the following sections of the Stafford Act: 403 (essential assistance), 406 (repair, restoration, and replacement of damaged facilities), 407 (debris removal), 408 (federal assistance to individuals and households), 410 (unemployment assistance), 416 (crisis counseling assistance and training), and 428 (public assistance program alternative program procedures)  These changes may increase the focus on funding public infrastructure projects that improve community resilience before a disaster occurs, although FEMA has the discretion to shape the program in many ways  There is potential for significantly increased funding post-DRRA through the new transfer from the DRF, but it is not yet clear how FEMA will implement this new program  Agency: Federal Emergency Management Agency Authority: 42 U S C  §5133 Regulation: 44 C F R  §201 Contact : Office of Congressional Affairs, 202-646-4500 Website: http://www fema gov/pre-disaster-mitigation-grant-program CFDA Program Number : 97 047 CRS Contact: Diane P  Horn, 202-707-3472 The Community Disaster Loan (CDL) program provides loans to local governments that have suffered substantial loss of tax and other revenue in areas included in a major disaster declaration  Typically, the loan may not exceed 25% of the local government's annual operating budget for the fiscal year of the disaster  The limit is 50% if the local government lost 75% or more of its annual operating budget  A loan may not exceed $5 million, and there is no matching requirement  The statute does not impose time limitations on the assistance, but the normal term of a loan is five years  The statute provides that the repayment requirement is cancelled if local government revenues are not sufficient to meet operations expenses during a three-fiscal-year period after a disaster  The governor's authorized representative must officially approve the application and funds must be available in the Disaster Assistance Direct Loan Program (DADLP) account  In P L  115-72 , Congress provided up to $4 9 billion for the CDL program to assist local governments in providing essential services as a result of Hurricanes Harvey, Irma, or Maria  However, this legislation departed from the traditional CDL program framework by giving the Secretary of Homeland Security (in consultation with the Secretary of the Treasury) broad authority over lending terms, eligible uses, and criteria for loan cancelation, among other program elements  As a result, this CDL-type program operates differently from the traditional program  For more information, see CRS Insight IN11106, Community Disaster Loans: Homeland Security Issues in the 116th Congress , by Michael H  Cecire  Agency: Federal Emergency Management Agency Authority: 42 U S C  §5184 Regulation: 44 C F R  §§206 360–206 378 Contact : Office of Congressional Affairs, 202-646-4500 CFDA Program Number : 97 030 CRS Contact: Michael H  Cecire, 202-707-7109 This program provides grants to state and local governments to aid states and their communities with the mitigation, management, and control of fires burning on publicly or privately owned forests or grasslands  The federal government provides 75% of the costs associated with fire management projects, but funding is limited to calculations of the "fire cost threshold" for each state  No time limitation is applied to the program  For more information, see CRS Report R43738, Fire Management Assistance Grants: Frequently Asked Questions , by Bruce R  Lindsay and Katie Hoover  Agency: Federal Emergency Management Agency Authority: 42 U S C  §5187 Regulation: 44 C F R  §§204 1–204 64 Contact : Office of Congressional Affairs, 202-646-4500 Website: https://www fema gov/fire-management-assistance-grant-program CFDA Program Number : 97 046 CRS Contact: Bruce R  Lindsay, 202-707-3752 Congress created the Oil Spill Liability Trust Fund (OSLTF) in 1986  Subsequent laws authorized the OSLTF taxing authority, appropriations from the fund, and eligible uses for the fund  The OSLTF complements the Oil Pollution Act of 1990 (OPA; P L  101-380 ), which established a new federal oil spill liability framework, replaced existing federal liability frameworks, and amended the existing Clean Water Act oil spill response authorities  In addition, OPA transferred monies into the OSLTF from existing liability funds  The OSLTF may be used, among other purposes, to fund oil spill response activities and to compensate individuals, businesses, and governments for applicable economic damages resulting from an oil spill  Potential damages include injury or loss of property and loss of profits or earning capacity  OPA established a claims process for compensating parties affected by an oil spill  In general, claims must be presented first to the party responsible for the spill, but specific circumstances (e g , the responsible party is unknown) allow persons to present a claim directly to the OSLTF  Agency : National Pollution Funds Center (part of the U S  Coast Guard) Authority : 26 U S C  §9509 and 33 U S C  §2712 Regulation : 33 C F R  §136 Contact : Office of Legislative Affairs, 202-245-0520 Website : http://www uscg mil/npfc/ CRS Contact : Jonathan L  Ramseur, 202-707-7919 This program assists small businesses and nonprofits suffering economic injury as a result of disasters by offering loans and loan guarantees  Businesses must be located in disaster areas declared by the President, the Small Business Administration, or the Secretary of Agriculture  There is no matching requirement in this program  The maximum loan amount is $2 million  Loan terms may extend for up to 30 years  The application period is announced at the time of the disaster declaration  For more information, see CRS Report R41309, The SBA Disaster Loan Program: Overview and Possible Issues for Congress , by Bruce R  Lindsay  Agency: Small Business Administration Authority: 15 U S C  §636(b) Regulation: 13 C F R  §§123 300–123 303 Contact : Office of Congressional Affairs, 202-205-6700 Website : https://disasterloan sba gov/ela/Information/EIDLLoans CFDA Program Number : 59 008 CRS Contact: Bruce R  Lindsay, 202-707-3752 This program provides loans to businesses and nonprofits in declared disaster areas for uninsured physical damage and losses  The maximum loan amount is $2 million  Loan terms may extend for up to 30 years  There is no matching requirement in this program  For more information, see CRS Report R41309, The SBA Disaster Loan Program: Overview and Possible Issues for Congress , by Bruce R  Lindsay  Agency: Small Business Administration Authority: 15 U S C  §636(b) Regulation: 13 C F R  §§123 200–123 204 Contact : Office of Congressional Affairs, 202-205-6700 Website: https://disasterloan sba gov/ela/Information/BusinessPhysicalLoans CFDA Program Number : 59 008 CRS Contact: Bruce R  Lindsay, 202-707-3752 When a county has been declared a disaster area by either the President or the Secretary of Agriculture, agricultural producers in that county may become eligible for low-interest emergency disaster (EM) loans available through the U S  Department of Agriculture's Farm Service Agency  Producers in counties that are contiguous to a county with a disaster designation also become eligible for an EM loan  EM loan funds may be used to help eligible farmers, ranchers, and aquaculture producers recover from production losses (e g , when the producer suffers a significant loss of an annual crop) or from physical losses (e g , repairing or replacing damaged or destroyed structures or equipment, or replanting permanent crops, such as orchards)  A qualified applicant can then borrow up to 100% of actual production or physical losses (not to exceed $500,000) at a below-market interest rate  For more information see CRS Report RS21212, Agricultural Disaster Assistance , by Megan Stubbs  Agency: Department of Agriculture, Farm Service Agency Authority: 7 U S C  §1961 Regulation: 7 C F R  §764 Contact : Legislative Liaison Staff, 202-720-7095 Website: https://www fsa usda gov/programs-and-services/farm-loan-programs/emergency-farm-loans/index CFDA Program Number : 10 404 CRS Contact: Megan Stubbs, 202-707-8707 Since 1968, the federal government has pursued a comprehensive flood risk management strategy designed to (1) identify and map flood-prone communities across the country (flood hazard mapping); (2) encourage property owners in NFIP participating communities to purchase insurance as a protection against flood losses (flood insurance); and (3) require communities in designated flood risk zones to adopt and enforce approved floodplain management ordinances to reduce future flood risk to new construction in regulated floodplains (floodplain management)  The Federal Insurance and Mitigation Administration (FIMA), a part of FEMA, manages the NFIP  For more information, see CRS Report R44593, Introduction to the National Flood Insurance Program (NFIP) , by Diane P  Horn and Baird Webel, and CRS In Focus IF11023, Selected Issues for National Flood Insurance Program (NFIP) Reauthorization and Reform , by Diane P  Horn  Agency: Federal Emergency Management Agency Authority: 42 U S C  §4001 et seq  Regulation: 44 C F R  §59 1–§82 21 Contact : Office of Congressional Affairs, 202-646-4500 Website: http://www fema gov/national-flood-insurance-program CFDA Program Number : 97 022 CRS Contact : Diane Horn, 202-707-3472 In addition to programs described above that provide targeted assistance to individuals, states, territories, local governments, and businesses specifically affected by disasters, other general assistance programs may be useful to communities in disaster situations  For example, individuals who lose income, employment, or health insurance may become eligible for programs that are not specifically intended as disaster relief, such as cash assistance under the Temporary Assistance for Needy Families (TANF) program, job training under the Workforce Investment Act, Medicaid, or the State Children's Health Insurance Program (S-CHIP)  Likewise, state or local officials have the discretion to use funds under programs such as the Social Services Block Grant or Community Development Block Grant to meet disaster-related needs, even though these programs were not established specifically for such purposes  Other agencies may offer assistance to state and local governments, including the Economic Development Administration and the Army Corps of Engineers  For businesses, however, only the disaster programs administered by the Small Business Administration are generally applicable  Numerous other federal programs could offer disaster relief, but specific eligibility criteria or other program rules might make it less likely that they would actually be used  Moreover, available funds might already be obligated for ongoing program activities  To the extent that federal agencies have discretion in the administration of programs, some agencies may choose to adapt these non-targeted programs for use in disaster situations  Also, Congress may choose to provide additional funds through emergency supplemental appropriations for certain general assistance programs, specifically for use after a disaster  CRS analysts and program specialists can help provide information regarding general assistance programs that might be relevant to a given disaster situation  CRS appropriations reports may have information on disaster assistance within particular federal agencies  These reports also list CRS's key policy staff by their program area and agency expertise  CRS Report R41981, Congressional Primer on Responding to Major Disasters and Emergencies , by Bruce R  Lindsay and Elizabeth M  Webster CRS Report R41101, FEMA Disaster Cost-Shares: Evolution and Analysis , by Natalie Keegan and Elizabeth M  Webster CRS Report RL33330, Community Development Block Grant Funds in Disaster Relief and Recovery , by Eugene Boyd CRS Report RL33579, The Public Health and Medical Response to Disasters: Federal Authority and Funding , by Sarah A  Lister CRS Report R44593, Introduction to the National Flood Insurance Program (NFIP) , by Diane P  Horn and Baird Webel CRS Insight IN10450, Private Flood Insurance and the National Flood Insurance Program (NFIP) , by Baird Webel and Diane P  Horn CRS Report R45099, National Flood Insurance Program: Selected Issues and Legislation in the 115th Congress , by Diane P  Horn CRS In Focus IF10730, Tax Policy and Disaster Recovery , by Molly F  Sherlock CRS Report R41884, Considerations for a Catastrophic Declaration: Issues and Analysis , by Bruce R  Lindsay CRS Report R43784, FEMA's Disaster Declaration Process: A Primer , by Bruce R  Lindsay CRS Report R43738, Fire Management Assistance Grants: Frequently Asked Questions , by Bruce R  Lindsay and Katie Hoover CRS Report R45085, FEMA Individual Assistance Programs: In Brief , by Shawn Reese CRS Report R45238, FEMA and SBA Disaster Assistance for Individuals and Households: Application Process, Determinations, and Appeals , by Bruce R  Lindsay and Shawn Reese CRS Report RS22022, Disaster Unemployment Assistance (DUA) , by Julie M  Whittaker CRS Report R41309, The SBA Disaster Loan Program: Overview and Possible Issues for Congress , by Bruce R  Lindsay CRS Report RS21212, Agricultural Disaster Assistance , by Megan Stubbs CRS Report R42854, Emergency Assistance for Agricultural Land Rehabilitation , by Megan Stubbs CRS In Focus IF10565, Federal Disaster Assistance for Agriculture , by Megan Stubbs CRS In Focus IF10730, Tax Policy and Disaster Recovery , by Molly F  Sherlock CRS Report R44808, Federal Disaster Assistance: The National Flood Insurance Program and Other Federal Disaster Assistance Programs Available to Individuals and Households After a Flood , by Diane P  Horn CRS Insight IN11094, The Evolving Use of Disaster Housing Assistance and the Roles of the Disaster Housing Assistance Program (DHAP) and the Individuals and Households Program (IHP) , by Elizabeth M  Webster CRS Insight IN11054, Disaster Housing Assistance: Homeland Security Issues in the 116th Congress , by Elizabeth M  Webster CRS Insight IN11106, Community Disaster Loans: Homeland Security Issues in the 116th Congress , by Michael H  Cecire Note: Because not all agencies have complete, up-to-date information available on the internet, in particular during and immediately after a disaster, congressional users are encouraged to contact the appropriate CRS program analysts or department or agency program officers for more complete, timely information  USA gov http://www USA gov/ Many federal agencies have established websites specifically for responding to disasters  Some agencies maintain websites with comprehensive information about their disaster assistance programs, whereas others supply only limited information; most list contact phone numbers  An A-Z index of U S  government departments and agencies is available at the website above  FEMA Website http://www fema gov From its website, FEMA offers regular updates on recovery efforts in areas under a major disaster declaration  Information on a specific disaster may include a listing of declared counties and contact information for local residents  Disaster Assistance gov http://www disasterassistance gov/ DisasterAssitance gov provides information on how help might be obtained from the U S  government before, during, and after a disaster  The website includes tools to find, apply for, and check the status of assistance by category or agency  The website also includes disaster-related news feeds and information on community resources  Assistance Listings at beta SAM gov https://beta SAM gov/ Official descriptions of more than 2,200 federal assistance programs, including disaster and recovery grants and loans, can be found on beta SAM gov  The website is currently in beta, and it houses federal assistance listings previously found on the now-retired Catalog of Federal Domestic Assistance (CFDA)  For programs summarized in this report, CFDA program numbers are given (which are searchable at the "Assistance Listings" domain at beta SAM gov)  Full assistance listing descriptions, updated by departments and agencies, cover authorizing legislation, objectives, and eligibility and compliance requirements  For current appropriations and additional information, users can contact CRS analysts, or departments and agencies 


Report 2:  The provider emphasized concerns about the long-term viability of caring for those patients at the facility, because their care is paid at lower rates  Our review of Medicare claims data, other information, and interviews with stakeholders indicated the two qualifying hospitals treated Medicare beneficiaries with different conditions than most of those treated at other LTCHs  Our analysis of Medicare claims data indicates Craig Hospital and Shepherd Center treat very few patients in the Medicare diagnosis groups that are most common to other LTCHs  Specifically, for several years, MedPAC has reported that LTCH patient discharges are concentrated in a relatively small number of diagnosis groups  For example, in March 2018, MedPAC reported that 20 diagnosis groups accounted for over 61 percent of LTCH discharges at both for-profit and not-for-profit facilities, in fiscal year 2016  However, in fiscal year 2016, these diagnosis groups accounted for approximately 30 percent of Medicare discharges—26 out of 88—at Shepherd Center, and most of these discharges fell within a single diagnosis group which covers a range of conditions  Craig Hospital did not discharge any Medicare beneficiaries assigned to these 20 diagnosis groups, in fiscal year 2016  The seven diagnosis groups that were used in the statutory criteria to except Craig Hospital and Shepherd Center from site-neutral payments were also not among these 20 diagnosis groups  For more information on the 20 diagnosis groups common to LTCHs in fiscal year 2016, see Appendix III, table 5  Our review of Medicare claims data and other information indicates the two qualifying hospitals also treat a relatively small number of Medicare beneficiaries, a key distinguishing factor from most other LTCHs  In March 2018, MedPAC reported that, on average, Medicare beneficiaries account for about two-thirds of LTCH discharges  However, Medicare claims data and other information provided by the two qualifying hospitals indicate Medicare beneficiaries account for a significantly smaller proportion (about 8 percent) of patients discharged from Craig Hospital and Shepherd Center in 2016  Specifically, 40 of the 486 patients discharged from Craig Hospital in fiscal year 2016 and 75 of the 912 patients discharged from Shepherd Center in calendar year 2016, were Medicare beneficiaries  Officials from the qualifying hospitals told us they treat few Medicare patients primarily because of the younger average age of persons with spinal cord injuries and acquired brain injuries  While patients with spinal cord and brain injuries may receive care in other LTCHs, most stakeholders we interviewed also suggested the two qualifying hospitals treat patients that are different from those treated at most other LTCHs, and can offer specialized care  Officials from the two qualifying hospitals told us that, relative to most other facilities—including most traditional LTCHs—they offer a more complete continuum of care to meet the needs of patients at different stages of spinal cord and brain injury treatment, without the need to transfer to different facilities  Officials also stated that, unlike most traditional LTCHs, they are able to offer more specialized care for patients with spinal cord and brain injuries, including more comprehensive rehabilitation services  Stakeholders we interviewed generally agreed that the two qualifying hospitals have developed expertise in treating spinal cord and brain injury patients and offer intensive rehabilitation services that are not provided in most other LTCHs  In addition, officials from the Colorado Department of Health Care Policy & Financing noted that Craig Hospital treats a patient population that is different from most other LTCHs in the state of Colorado  Specifically, according to officials, in comparison to other LTCHs in the state, Craig Hospital treats: (1) a higher percentage of patients with more severe conditions, (2) more patients from outside the state of Colorado, (3) fewer patients requiring ventilator weaning or requiring wound care— conditions typically characteristic of LTCH patients—and (4) patients that are, on average, younger than most other LTCHs in the state of Colorado  In addition, a 2014 study of LTCHs conducted for the Georgia Department of Community Health found Shepherd Center was “distinctly different” from other LTCHs in the state of Georgia, and most LTCHs nationwide  Most stakeholders we interviewed suggested some IRFs provide specialty care to patients with catastrophic spinal cord, acquired brain injuries, or other paralyzing neuromuscular conditions  Most of the stakeholders we interviewed noted that—like the two qualifying hospitals—some IRFs have the expertise to treat patients with catastrophic spinal cord, acquired brain injuries, or other paralyzing neuromuscular conditions patients and thus, may also treat patients with similar conditions  According to CMS officials, IRFs are specifically designed to provide post-acute rehabilitation services to patients with spinal cord injuries, brain injuries, and other neuromuscular conditions  CMS officials noted that patients with these conditions typically respond well to intensive rehabilitation therapy provided in a resource intensive inpatient hospital environment and to the specific interdisciplinary approach to care that is provided in the IRF setting  Stakeholders also noted that patients with spinal cord injuries, brain injuries, and other neuromuscular conditions may receive care in other settings  However, some stakeholders noted that some of these providers—such as skilled nursing facilities—generally do not offer the specialized care these patients generally require  Differences in payment systems and data limitations make it difficult to directly compare the attributes of Medicare beneficiaries discharged from the two qualifying hospitals and IRFs, including the costs of care they receive  Medicare uses separate payment systems to pay LTCHs and IRFs, for care provided to beneficiaries  LTCHs are paid pre-determined fixed amounts for care provided to Medicare beneficiaries, under the LTCH PPS  Medicare beneficiaries treated in LTCHs are assigned to diagnosis groups (MS-LTC-DRGs) for each stay—based on the patient’s primary and secondary diagnoses, age, gender, discharge status, and procedures performed  IRFs are also paid pre-determined fixed amounts for care provided to Medicare beneficiaries, but under a separate system—IRF PPS  Medicare beneficiaries treated in IRFs are assigned to case-mix groups—based on age, and level of motor and cognitive function—and then further assigned to one of four tiers (within these groups) based on the presence of specific comorbidities that may increase their cost of care  According to CMS officials, because the payment groups and assignments to those groups are different, it is difficult to directly compare LTCH patients, classified in diagnosis groups, with IRF patients, classified in case-mix groups  See Appendix II for more information on these payment systems  MedPAC has previously reported the differences in patient assessment tools used by post-acute care providers undermines Medicare’s ability to compare the patients admitted, costs of care, and outcomes beneficiaries achieve in these settings, on a risk-adjusted basis  MedPAC has also reported that while similar beneficiaries can receive care in each setting, payments can differ considerably for comparable conditions, due to differences in payment systems  It has made recommendations to address these issues  The Improving Medicare Post-Acute Care Transformation Act of 2014 also requires the Secretary of HHS to collect and analyze common patient assessment information and, in consultation with MedPAC, submit a report to Congress recommending a post-acute care PPS  Such efforts may make future comparison of beneficiaries, costs of services, and outcomes of care across these settings possible  While data limitations make a direct comparison difficult, based on our review of other data and information, and interviews with stakeholders, we identified similarities and differences between the qualifying hospitals and certain IRFs that provide specialty treatment for catastrophic spinal cord injuries, acquired brain injuries, or other paralyzing neuromuscular conditions  Key similarities and differences include the following: Volume of services  Our review of Medicare claims data, other information, and interviews with stakeholders indicate that—similar to the two qualifying hospitals—some IRFs treat a high volume (at least 100) of patients with complex spinal cord injury, brain injury, and other related conditions  Officials from the two qualifying hospitals, as well as some other stakeholders we interviewed—including officials from the Christopher & Dana Reeve Foundation and the Brain Injury Association of America—emphasized the importance of facilities treating a high volume of patients with these specialized conditions, which can be an indicator of expertise in treating these patients  Our review of Medicare claims data for 1,148 IRFs in fiscal year 2016 identified 21 IRFs that treated at least 100 Medicare beneficiaries with non-traumatic and traumatic spinal cord injuries and 109 IRFs that treated at least 100 Medicare beneficiaries with non-traumatic and traumatic brain injuries  Our review of Medicare claims data indicated that, similar to the two qualifying hospitals—some IRFs also treat a high volume of patients with “catastrophic” injuries—traumatic brain injury, traumatic spinal cord injury, and major multiple traumas with brain or spinal cord injuries  Specifically, we identified 25 IRFs that treated a high volume (at least 100) of Medicare beneficiaries with catastrophic injuries, in fiscal year 2016  In the absence of patient assessment data from the facilities, we did not independently evaluate the level and severity of these patients’ injuries, which can vary due to the presence of other co-morbid conditions  The Medicare case mix indexes we reviewed for these 25 IRFs indicated that, relative to other IRFs, most of these facilities treat patients who are more resource intensive  Specialty accreditation and designation as model systems  Like Shepherd Center, some IRFs receive CARF-accreditation for specialty programs to treat spinal cord and brain injuries  According to most stakeholders, this accreditation indicates expertise in treating these patients, as CARF International has established standards using evidence-based practices, among other factors  Officials from the two qualifying hospitals also noted CARF International has a specific focus on quality and outcomes  However, officials from Shepherd Center noted similarities in care and services offered at CARF-accredited facilities would depend on the specialties for which they are certified  Most of the stakeholders we interviewed also noted that designation as a NIDILRR model system is an indicator of similar expertise in treating patients with spinal cord and brain injuries  According to the Model Systems Knowledge Translation Center, spinal cord injury and brain injury model systems are recognized as national leaders in medical research and patient care and provide the highest level of comprehensive specialty services from the point of injury through eventual re-entry into full community life  While stakeholders we interviewed from NIDILRR model systems indicated the model system designation is focused primarily on research, rather than clinical care, most noted that model systems’ research often complements the facilities’ clinical efforts to address the unique needs of these patients  Officials from HHS’s Administration for Community Living also noted that all model system grantees must provide a continuum of care—emergency care, acute medical care, acute medical rehabilitation, and post-acute care—and that can happen in various provider types  According to officials from the qualifying hospitals and stakeholders from one other NIDILRR model system we interviewed, Craig Hospital and Shepherd Center are the only two LTCHs currently classified as spinal cord injury model systems; 12 of 14 spinal cord injury model systems are IRFs  Specialized programs and services  Similar to the two qualifying hospitals, some IRFs may also offer specialized programs and services for patients with brain and spinal cord injuries, but the availability of these programs and services may vary by facility  Officials from some of the IRFs that responded to our information request—which included both NIDILRR facilities and IRFs with CARF-accredited programs—told us they provide specialized programs and services for patients with similar conditions as those treated at two qualifying hospitals, and sometimes compete with the two qualifying hospitals for the same patients  For example, each IRF reported having interdisciplinary treatment teams; the capacity to provide medical management of medically complex and high acuity patients with spinal cord injury, traumatic brain injury, or other major multiple traumas associated with a brain or spinal cord injury; family education and training; and skin and wound programs or services, among other services  However, the availability of certain services—including but not limited to ventilator-dependent weaning programs, diaphragmatic pacing, and outpatient programs for spinal cord and traumatic brain injury patients—varied by facility  Staff with specialized training and clinical expertise  Similar to the two qualifying hospitals, most facilities that responded to our information request also reported having physicians, nurses, and physical and occupational therapists with specialty training in medical rehabilitation, spinal cord, and/or brain injury  However, the number of staff with these trainings, varied by facility  In comparison to the other facilities that responded to our information request, the number of nurses and physical and occupational therapists with these specialty trainings were generally higher at Craig Hospital and Shepherd Center  According to an American Spinal Injury Association consumer guideline that the Christopher & Dana Reeve Foundation typically provides to spinal cord injury patients and families, programs should regularly admit persons with spinal cord injury each year, to develop and maintain the necessary skills to manage a person with spinal cord injury, and a substantial portion of those admitted should have traumatic injuries  Out-of-state Admissions  Officials from the two qualifying hospitals emphasized they admit a significant number of patients from out-of-state, and our review of information provided by the qualifying hospitals and a select group of IRFs indicated the qualifying hospitals admit a higher percentage of patients from out-of-state  Specifically, information provided by these IRFs indicates that less than a quarter of patients admitted to these facilities, in 2016, were from out-of-state  Information provided by Craig Hospital and Shepherd Center indicate that about half of their patients were admitted from out-of-state in 2016  Officials from the Colorado Department of Health Care Policy & Financing also noted Craig Hospital treats a higher percentage of out-of-state patients, compared to IRFs in the state  Ability to treat medically complex patients  Officials from the two qualifying hospitals told us they treat more medically complex patients and provide a more complete range of medical services to spinal cord and brain injury patients, not provided by most IRFs  Specifically, officials from the two qualifying hospitals both noted they are able to treat patients much sooner in their recovery process than most IRFs, due to their LTCH status  Officials from the Shepherd Center noted that they have a 10-bed intensive care unit which allows them to take patients with certain injures that some IRFs may not be equipped to admit—such as patients requiring advance medical management and advanced level procedural services and monitoring  Information provided by Shepherd Center indicated that, in calendar year 2017, approximately 20 percent of all inpatients were admitted to this unit and 13 percent of all inpatients were internally transferred to this unit after developing medical complications  According to officials, Craig Hospital does not have an intensive care unit, but noted their ability to similarly care for medically complex patients—including telemetry (e g , specialized heart monitoring) and one-to-one nursing care, if necessary  Most stakeholders we interviewed agreed that both qualifying hospitals’ LTCH status provides certain advantages over IRFs, such as the ability to admit some medically complex patients earlier in the recovery process and longer lengths of stay  Stakeholders from most of the IRFs we interviewed also reported having the flexibility to admit some medically complex patients requiring more advanced level monitoring and resources earlier in the recovery process—such as patients with disorders of consciousness  Officials from the two qualifying hospitals also said they offer a continuum of care that can meet patient’s changing needs, without the need to transfer them to different facilities  Information provided by Craig Hospital indicated that 83 percent of patients treated at its facility, in 2016, were discharged to home, 13 percent were discharged to another post-acute care facility, and 3 percent were discharged to an acute care hospital  In 2016, approximately 91 percent of patients treated at Shepherd Center were discharged to home, 7 percent were discharged to another post- acute care facility, and 2 percent were discharged to an acute care hospital  Information provided by the IRFs that responded to our written request varied by facility, but—similar to the two qualifying hospitals— each facility discharged more than 65 percent of patients to home  IRF payment criteria  CMS and most other stakeholders we interviewed noted that two Medicare payment policies applicable to IRFs, but not LTCHs, may contribute to their different patient populations  Specifically, to be classified for payment under Medicare’s IRF PPS, at least 60 percent of the IRF’s total inpatient population must require intensive rehabilitative treatment for one or more of 13 conditions—which includes both spinal cord and brain injury  To be admitted to an IRF, Medicare beneficiaries must reasonably be expected to actively participate in and benefit from the intensive rehabilitation therapy program, typically provided in IRFs  According to HHS, per industry standard, the intensive rehabilitation therapy program is often demonstrated by providing three hours of rehabilitation services per day for at least five days per week, but this is not the only way such intensity can be demonstrated  Officials from the two qualifying hospitals told us they generally use Medicare’s intensive rehabilitation requirement as a minimum standard for their rehabilitation patients—even though they are not held to this requirement, for the purposes of Medicare payment—but noted that some of their patients may not meet this requirement, due to their medical complexity  Length of stay and site-neutral payment requirements, for LTCHs  As previously noted, LTCHs—including the two qualifying hospitals—must have an average length of stay of greater than 25 days; IRFs are not subject to this requirement  The average length of stay for patients discharged from the Craig Hospital was about 60 days, in fiscal year 2016, and the average length of stay for patients discharged from Shepherd Center was about 53 days, in calendar year 2016  Stakeholders from the IRFs that responded to our information request reported average lengths of stay ranging from 14 to 31 days, for patients discharged in fiscal year 2016; the ranges of lengths of stay were slightly higher for spinal cord injury and traumatic brain injury inpatients for the IRFs, during the same period  LTCHs are also generally subject to site- neutral payment policy that is not applicable to IRFs and may decrease LTCHs payments for certain discharges, under Medicare  Other services provided  In addition to these Medicare specific differences, a few stakeholders we interviewed also noted the two qualifying hospitals receive additional funding from their strong philanthropic donor base that may allow them to provide other services and resources, not covered by Medicare or offered at some IRFs  For example, while a few IRFs that responded to our information request reported offering housing for families of injured patients, the two qualifying hospitals offer up to 30 days of free housing to families of newly injured rehabilitation patients, if both the family and patient live more than 60 miles from the hospital  Officials from Shepherd Center told us their revenues are supplemented by investment income and donor funds  Craig Hospital has also established a foundation that supports the hospital in achieving its goals through philanthropy  We provided a draft of this report to HHS  HHS provided technical comments, which we incorporated as appropriate  We also provided the two qualifying hospitals summaries of information we collected from them, to confirm the accuracy of statements included in our draft report  We incorporated their comments, as appropriate  We are sending copies of this report to the Secretary of Health and Human Services and other interested parties  In addition, the report will be available at no charge on GAO’s website at http://www gao gov  If you or your staff have any questions about this report, please contact me at (202) 512-7114 or at farbj@gao gov  Contact points for our Office of Congressional Relations and Office of Public Affairs can be found on the last page of this report  Other major contributors to this report are listed in appendix IV  This appendix describes our methodology for conducting simulations of payments for the two qualifying hospitals  We used Medicare claims data to conduct simulations of payments for the two qualifying hospitals  We first identified discharges at each hospital in two baseline years—federal fiscal years 2013 and 2016  We selected fiscal year 2016 because it was the year with the most recent data available at the time of our analysis, and we selected a second baseline year because data for 2016 was different than data for other recent years  For example, the number of discharges for one qualifying hospital declined by nearly half between fiscal years 2013 and 2016  We chose fiscal year 2013 because data from that year was used to help determine which hospitals are subject to the temporary exception  To identify how to appropriately calculate the long-term care hospital (LTCH) payment for each of these discharges in future payment years, we reviewed applicable federal regulation and documents from the Centers for Medicare & Medicaid Services (CMS) and the Medicare Payment Advisory Commission (MedPAC), and interviewed officials from both organizations  See table 4 for the relevant components in the formulas, such as Medicare severity long-term care diagnosis related group (MS-LTC-DRG) weights, identified from final rule tables  When conducting these simulations, we made the following assumptions: For simulated payments for payment policies in effect for fiscal years 2017 and 2018, we used the base rates, relative weights (e g , the MS-LTC-DRG weights), geometric mean length of stay, wage index, geographic adjustment factor, fixed-loss amounts, and outlier thresholds that were published in the final rule tables for LTCH and inpatient prospective payment system (IPPS) hospitals—also known as acute care hospitals—for each respective year  At the time we began our analysis, this information was not known for fiscal years 2019 through 2021  We chose to use the fiscal year 2018 rates when conducting simulations for payment policies in those years because historical trends showed that annual changes were minimal—about 1 percent  Therefore, to the extent that these values continue to change over time, our findings may understate or overstate the amount that the qualifying hospitals would have been paid in our baseline years based on these future payment policies  The site-neutral payment policy did not apply to discharges from the fiscal year 2013 baseline year  Therefore, we examined Medicare claims data to determine whether each discharge would have met the criteria to receive the LTCH standard rate in that year  Specifically, we determined whether each discharge had an acute care hospital stay that immediately preceded their LTCH stay  We then determined whether the time at the acute care hospital included three or more days in the intensive care unit or whether there was a code on the LTCH claim that indicated at least 96 hours of mechanical ventilation services were provided  Per Medicare’s payment policy, we assumed any discharge that met these two criteria would qualify for full LTCH payment rate, unless the case was a psychiatric or rehabilitation stay, as identified by the following MS-LTC-DRG codes: 876, 880, 881, 882, 883, 884, 885, 886, 887, 894, 895, 896, 897, 945, or 946  Under statute, unless 50 percent or more of the hospital’s discharges beginning during or after 2020 qualify for the standard rate, no subsequent payments will be made to a hospital at that rate  Therefore, when calculating simulated payments for fiscal year 2021, we applied the 50 percent threshold  At the time of our analysis, CMS had not yet finalized this policy through rule-making  As of November 2018, CMS officials told us that it is unlikely that any payment adjustment under this provision would apply until 2022 because the percentage cannot be determined until after an LTCH’s cost reporting period has ended and data have been submitted  Shepherd Center’s fiscal year is different than the federal fiscal year  Therefore, the variables used to determine whether discharges in federal fiscal year 2016 met criteria to receive the standard rate were not available to use for some of the discharges that year  Of those discharges, we assumed that the same percentage of discharges that met the criteria to receive the standard rate in Shepherd’s fiscal year—30 percent—met the criteria in federal fiscal year 2016  When calculating site-neutral payments, we assumed that each discharge would be paid at a rate comparable to that for acute care hospitals—the IPPS comparable amount rate  Site-neutral payments may also be based on the estimated cost-of-care, if it is lower than the IPPS comparable amount rate  However, over 90 percent of discharges at the qualifying hospitals were paid at the IPPS comparable amount rate in fiscal year 2016  Per CMS’s recommendation, we applied the cost-to-charge ratio that was effective October 1, 2017, for each qualifying hospital, regardless of discharge date  For Craig Hospital this value was 0 442 and for Shepherd Center this value was 0 464  According to CMS officials, in general, these values do not change significantly when they are updated during the fiscal year  Therefore, they believe that using the values effective at the start of the fiscal year is a reasonable assumption  We excluded indirect medical education adjustments and disproportionate share hospital payments that are part of the IPPS comparable amount rate because, according to CMS, they were unlikely to have much impact for these hospitals  CMS reviewed each of these assumptions and agreed they were reasonable for purposes of our analysis  CMS also verified that we were correctly applying the formulas for calculating these payments and using the appropriate values from the final rules  Figures 3 and 4 illustrate the methodology for calculating Medicare payments under the long-term care hospital (LTCH) prospective payment system (PPS) and the inpatient rehabilitation facility (IRF) PPS, respectively, as reported by the Medicare Payment Advisory Commission (MedPAC)  Appendix III: List of Common Diagnosis Groups for Long-Term Care Hospitals (LTCH) In its March 2018 annual report to the Congress, the Medicare Payment Advisory Commission (MedPAC) reported that 20 diagnosis groups accounted for over 61 percent of LTCH discharges at both for-profit and not-for-profit facilities, in fiscal year 2016  Table 5 provides a list of these 20 diagnosis groups  In addition to the contact named above, Will Simerl, Assistant Director; Kathy King; Amy Leone, Analyst-in-Charge; Todd Anderson; Sam Amrhein; LaKendra Beard; Rich Lipinski; Jennifer Rudisill; and Eric Wedum made key contributions to this report  Also contributing were Leia Dickerson, Diona Martyn, Vikki Porter, and Lisa Rogers 

ground_truth: The Centers for Medicare & Medicaid Services pays LTCHs for care provided to Medicare beneficiaries. There were about 400 LTCHs across the nation in 2016. The 21st Century Cures Act included a provision for GAO to examine certain issues pertaining to LTCHs. This report examines (1) the health care needs of Medicare beneficiaries who receive services from the two qualifying hospitals; (2) how Medicare LTCH payment polices could affect the two qualifying hospitals; and (3) how the two qualifying hospitals compare with other LTCHs and other facilities that may treat Medicare patients with similar conditions. GAO analyzed the most recently available Medicare claims and other data for the two qualifying hospitals and other facilities that treat patients with spinal cord injuries. GAO also interviewed HHS officials and stakeholders from the qualifying hospitals, other facilities that treat spinal cord patients, specialty associations, and others. GAO provided a draft of this report to HHS. HHS provided technical comments, which were incorporated as appropriate. We also provided the two qualifying hospitals summaries of information we collected from them, to confirm the accuracy of statements included in our draft report. We incorporated their comments, as appropriate. Spinal cord injuries may result in secondary complications that often lead to decreased functional independence and quality of life. The 21st Century Cures Act changed how Medicare pays certain long-term care hospitals (LTCH) that provide spinal cord specialty treatment. For these hospitals, the act included a temporary exception from how Medicare pays other LTCHs. Two LTCHs—Craig Hospital in Englewood, Colorado and Shepherd Center in Atlanta, Georgia—have qualified for this exception. GAO found that most Medicare beneficiaries treated at these two hospitals typically receive specialized care for multiple chronic conditions and other long-term complications that develop after initial injuries, such as pressure ulcers that can result in life-threatening infection. The two hospitals also provide specialty care for acquired brain injuries, such as traumatic brain injuries. GAO's simulations of Medicare payments to these two hospitals using claims data from two baseline years—fiscal years 2013 and 2016—illustrate potential effects of payment policies. LTCHs are paid under a two-tiered system for care provided to beneficiaries: they receive the LTCH standard federal payment rate—or standard rate—for certain patients discharged from the LTCH, and a generally lower rate—known as a “site-neutral” rate—for all other discharges. Under the temporary exception, Craig Hospital and Shepherd Center receive the standard rate for all discharges during fiscal years 2018 and 2019. Assuming their types of discharges remain the same as in fiscal years 2013 and 2016, GAO's simulations of Medicare payments in the baseline years indicate: Most of the discharges we examined would not qualify for the standard rate, if the exception did not apply. Medicare payments would generally decrease under fiscal year 2020 payment policy, once the exception expires. However, the actual effects of Medicare's payment policies on these two hospitals could vary based on factors, including the severity of patient conditions (e.g., Medicare payment is typically higher for more severe injuries), and whether hospitals' discharges meet criteria for the standard rate. Similarities and differences may exist between the two qualifying hospitals and other facilities that treat Medicare patients with spinal cord and brain injuries. Patients with spinal cord and brain injuries may receive care in other LTCHs, but GAO found that most Medicare beneficiaries at these other LTCHs are treated for conditions other than spinal cord and brain injuries. Certain inpatient rehabilitation facilities (IRF) also provide post-acute rehabilitation services to patients with spinal cord and brain injuries. While data limitations make a direct comparison between these facilities and the two qualifying hospitals difficult, GAO identified some similarities and differences. For example, officials from some IRFs we interviewed reported providing several of the same programs and services as the two qualifying hospitals to medically complex patients, but the availability of services and complexity of patients varied. Among other reasons, the different Medicare payment requirements that apply to LTCHs and IRFs affect the types of services they provide and the patients they treat.