I 

113TH CONGRESS 

1ST SESSION H. R. 3245 

To amend title XVIII of the Social Security Act to establish a maximum 

threshold for episode reimbursement to skilled home health agencies 

under Medicare. 

IN THE HOUSE OF REPRESENTATIVES 

OCTOBER 4, 2013 

Mr. MATHESON (for himself and Mr. GUTHRIE) introduced the following bill; 

which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of 

such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To amend title XVIII of the Social Security Act to establish 

a maximum threshold for episode reimbursement to 

skilled home health agencies under Medicare. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Medicare Home Health 

5 Fraud Reduction Act’’. 


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1 SEC. 2. ESTABLISHMENT OF MAXIMUM THRESHOLD FOR 

2 EPISODE REIMBURSEMENT TO SKILLED 

3 HOME HEALTH AGENCIES UNDER MEDICARE. 

4 Section 1895(b) of the Social Security Act (42 U.S.C. 

5 1395fff(b)) is amended by adding at the end the following 

6 new paragraph: 

7 ‘‘(7) EPISODE UTILIZATION RATE.— 

8 ‘‘(A) PAYMENT LIMITATION.—For 2014 

9 and each subsequent year, payment may not be 

10 made to a skilled home health agency under 

11 this section for an episode of care to the extent 

12 that such episode exceeds the applicable episode 

13 utilization limit established under subparagraph 

14 (B) for the agency for the year. 

15 ‘‘(B) APPLICABLE EPISODE UTILIZATION

16 LIMIT.— 

17 ‘‘(i) IN GENERAL.—For 2014 and 

18 each subsequent year, the Secretary shall 

19 establish an episode utilization limit for a 

20 skilled home health agency that is equal to 

21 the product of— 

22 ‘‘(I) in the case of a skilled home 

23 health agency located in— 

24 ‘‘(aa) a rural area, 3.3 epi25 sodes; and 


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1 ‘‘(bb) in an area not de2 scribed in item (aa), 2.7 episodes; 

3 and 

4 ‘‘(II) the total number of Medi5 care beneficiaries for the skilled home 

6 health agency (as defined in clause 

7 (iii)). 

8 ‘‘(ii) EPISODE DEFINED.—For pur9 poses of this paragraph, the term ‘episode’ 

10 has the meaning given such term for pur11 poses of section 484.205 of title 42, Code 

12 of Federal Regulations (as in effect on Oc13 tober 1, 2011) and includes partial epi14 sodes for which a partial episode payment 

15 is made pursuant to such section to the ex16 tent such partial episode is a percentage of 

17 a full episode. 

18 ‘‘(iii) TOTAL NUMBER OF MEDICARE

19 BENEFICIARIES DEFINED.— 

20 ‘‘(I) IN GENERAL.—For purposes 

21 of clause (i)(II), the term ‘total num22 ber of Medicare beneficiaries’ means, 

23 with respect to a skilled home health 

24 agency and year, the total number of 

25 unduplicated individuals who were 


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1 furnished home health services under 

2 this title in the year by the agency. 

3 ‘‘(II) SPECIAL RULE.—In calcu4 lating the total number of Medicare 

5 beneficiaries under subclause (I), in 

6 any case where an individual is fur7 nished skilled home health care serv8 ices from more than one agency, the 

9 number of such individuals being 

10 counted toward the applicable episode 

11 utilization limit for each such agency 

12 shall be proportionally credited in an 

13 amount equal to the percentage of the 

14 total number of episodes provided by 

15 the agency.’’. 

Æ 


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