II 

117TH CONGRESS 

1ST SESSION S. 2576 

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

to allow qualified group practices to furnish certain items and services 

at qualified skilled nursing facilities to individuals entitled to benefits 

under part A and enrolled under part B of the Medicare program 

to reduce unnecessary hospitalizations, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

JULY 30, 2021 

Mr. THUNE (for himself and Mr. CARDIN) introduced the following bill; which 

was read twice and referred to the Committee on Finance 

A BILL 

To amend title XVIII of the Social Security Act to establish 

a program to allow qualified group practices to furnish 

certain items and services at qualified skilled nursing 

facilities to individuals entitled to benefits under part 

A and enrolled under part B of the Medicare program 

to reduce unnecessary hospitalizations, and for other purposes. 

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


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Reducing Unnecessary 

3 Senior Hospitalizations Act of 2021’’ or the ‘‘RUSH Act 

4 of 2021’’. 

5 SEC. 2. SNF-BASED PROVISION OF PREVENTIVE ACUTE 

6 CARE AND HOSPITALIZATION REDUCTION 

7 PROGRAM. 

8 Title XVIII of the Social Security Act is amended by 

9 adding at the end the following new section: 

10 ‘‘SEC. 1899C. SNF-BASED PROVISION OF PREVENTIVE 

11 ACUTE CARE AND HOSPITALIZATION REDUC12 TION PROGRAM. 

13 ‘‘(a) ESTABLISHMENT.—There is established a pro14 gram to be known as the ‘SNF-based Provision of Preven15 tive Acute Care and Hospitalization Reduction Program’ 

16 (in this section referred to as the ‘Program’), to be admin17 istered by the Secretary, for purposes of reducing unneces18 sary hospitalizations and emergency department visits by 

19 allowing qualified group practices (as defined in section 

20 1877(h)(4)) on or after January 1, 2022, to furnish items 

21 and services identified under subsection (b)(3) to individ22 uals entitled to benefits under part A and enrolled under 

23 part B residing in qualified skilled nursing facilities. 

24 ‘‘(b) OPERATION OF PROGRAM.—Under the Pro25 gram, the Secretary shall provide for the following: 


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1 ‘‘(1) Certification of skilled nursing facilities as 

2 qualified skilled nursing facilities under subsection 

3 (c)(1). 

4 ‘‘(2) Certification of group practices as quali5 fied group practices under subsection (c)(2). 

6 ‘‘(3) Identification on an annual basis of min7 imum required, clinically appropriate nonsurgical 

8 items and services furnished at a hospital emergency 

9 department that may be safely furnished by a quali10 fied group practice at a qualified skilled nursing fa11 cility under the Program and that such qualified 

12 group practice shall offer to furnish under the Pro13 gram. Such items and services may include provider 

14 review of lab and imaging reports for medical deci15 sion making, medication management, blood glucose 

16 management, behavioral health services, and other 

17 services offered to diagnose or treat low acuity con18 ditions. 

19 ‘‘(4) Establishment of qualifications for non20 physician employees who may furnish such items 

21 and services at a qualified skilled nursing facility. 

22 Such qualifications shall include the requirement 

23 that such an employee— 

24 ‘‘(A) be certified in basic life support by a 

25 nationally recognized specialty board of certifiVerDate Sep 11 2014 16:10 Aug 04, 2021 Jkt 019200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S2576.IS S2576

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1 cation or equivalent certification board, in ac2 cordance with requirements under section 

3 483.24(a)(3) of title 42, Code of Federal Regu4 lations (or any successor regulation); and 

5 ‘‘(B) have— 

6 ‘‘(i) clinical experience furnishing 

7 medical care— 

8 ‘‘(I) in a skilled nursing facility; 

9 ‘‘(II) in a hospital emergency de10 partment setting; or 

11 ‘‘(III) as an employee of a pro12 vider or supplier of ambulance serv13 ices; or 

14 ‘‘(ii) a certification in paramedicine. 

15 ‘‘(5) Payment under this title for items and 

16 services identified under paragraph (3) furnished by 

17 such qualified group practices at such a facility in 

18 amounts determined under subsection (d). 

19 ‘‘(c) CERTIFICATIONS.— 

20 ‘‘(1) QUALIFIED SKILLED NURSING FACILI21 TIES.— 

22 ‘‘(A) IN GENERAL.—For purposes of this 

23 section, the Secretary shall certify a skilled 

24 nursing facility as a qualified skilled nursing fa25 cility if the facility submits an application in a 


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1 time and manner specified by the Secretary and 

2 meets the following requirements: 

3 ‘‘(i) The facility has on-site diagnostic 

4 equipment necessary for a qualified group 

5 practice to furnish items and services 

6 under the Program and real-time audio 

7 and visual capabilities as provided by the 

8 agreement between the facility and the 

9 qualified group practice. 

10 ‘‘(ii) The facility has at least one indi11 vidual who meets the qualifications de12 scribed in subsection (b)(4) or a physician 

13 present 24 hours a day and 7 days a week 

14 to work with the qualified group practice, 

15 in accordance with section 483.35(a) of 

16 title 42, Code of Federal Regulations (or 

17 any successor regulation). Such individual 

18 may be a member of the staff of the quali19 fied skilled nursing facility or of the quali20 fied group practice. 

21 ‘‘(iii) The facility ensures that resi22 dents of such facility, upon entering such 

23 facility, are allowed to specify in an ad24 vanced care directive or otherwise docu25 mented in the individual’s records whether 


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1 the resident wishes to receive items and 

2 services furnished at the facility under the 

3 Program in a case where communication 

4 with the resident is not possible. 

5 ‘‘(iv) The facility ensures that individ6 uals to be furnished such items and serv7 ices under the Program at such facility 

8 have the opportunity, at their request, to 

9 instead be transported to a hospital emer10 gency department. 

11 ‘‘(v) The facility is not part of the 

12 Special Focus Facility program of the Cen13 ters for Medicare & Medicaid Services (al14 though the facility may, at the discretion 

15 of the Secretary, be a candidate for selec16 tion under such program). 

17 ‘‘(B) REQUIRED PROVISION OF SERVICES

18 AND ACTIVITIES.—Nothing in this paragraph 

19 shall affect the application of requirements 

20 under section 1819(b)(4), relating to provision 

21 of services and activities, to a facility. 

22 ‘‘(2) QUALIFIED GROUP PRACTICES.—For pur23 poses of this section, the Secretary shall certify a 

24 group practice as a qualified group practice for a pe25 riod of 3 years if the group practice submits an apVerDate Sep 11 2014 16:10 Aug 04, 2021 Jkt 019200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S2576.IS S2576

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1 plication in a time and manner specified by the Sec2 retary and meets the following requirements: 

3 ‘‘(A) The group practice offers to furnish 

4 all minimum required items and services identi5 fied under subsection (b)(3) under the Pro6 gram. 

7 ‘‘(B) The group practice submits a notifi8 cation to the Secretary annually specifying 

9 which (if any) additional items and services 

10 identified under subsection (b)(3) for a year the 

11 group practice will offer to furnish for such 

12 year under the Program. 

13 ‘‘(C) The group practice ensures that only 

14 individuals who meet the qualifications estab15 lished under subsection (b)(4) or a physician 

16 who is part of such group practice may furnish 

17 such minimum required items and services and 

18 such additional items and services. 

19 ‘‘(D) The group practice, as provided by 

20 the agreement between the facility and the 

21 group practice or under the supervision of the 

22 medical director of the facility, ensures that, in 

23 the case where such minimum required items 

24 and services or such additional items and serv25 ices are furnished by such an individual, such 


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1 individual furnishes such minimum required 

2 items and services or additional items and serv3 ices under the supervision, either in-person or 

4 through the use of telehealth (not including 

5 store-and-forward technologies), of— 

6 ‘‘(i) a physician— 

7 ‘‘(I) who is board certified or 

8 board eligible in emergency medicine, 

9 family medicine, geriatrics, or internal 

10 medicine; or 

11 ‘‘(II) who has been certified by a 

12 nationally recognized specialty board 

13 of certification or equivalent certifi14 cation board in basic life support; 

15 ‘‘(ii) a nurse practitioner who has 

16 been certified by a nationally recognized 

17 specialty board of certification or equiva18 lent certification board in basic life sup19 port; or 

20 ‘‘(iii) a physician assistant who has 

21 been certified by a nationally recognized 

22 specialty board of certification or equiva23 lent certification board in basic life sup24 port. 


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1 ‘‘(E) With respect to any year in which the 

2 qualified group practice would participate in the 

3 Program, the Chief Actuary for the Centers for 

4 Medicare & Medicaid Services determines that 

5 such participation during such year will not re6 sult in total estimated expenditures under this 

7 title for such year being greater than total esti8 mated expenditures under such title for such 

9 year without such participation. 

10 ‘‘(d) PAYMENTS AND TREATMENT OF SAVINGS.— 

11 ‘‘(1) PAYMENTS.— 

12 ‘‘(A) IN GENERAL.—For 2022 and each 

13 subsequent year, payments shall continue to be 

14 made to qualified group practices and qualified 

15 skilled nursing facilities participating in the 

16 Program under the original Medicare fee-for17 service program under parts A and B in the 

18 same manner as they would otherwise be made 

19 except that such group practices and skilled 

20 nursing facilities are eligible to receive payment 

21 for shared savings under paragraph (2) if they 

22 meet the requirement under subparagraph 

23 (B)(i). 

24 ‘‘(B) SAVINGS REQUIREMENT AND BENCH25 MARK.— 


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1 ‘‘(i) DETERMINING SAVINGS.—In each 

2 year of the Program, a qualified group 

3 practice (and any qualified skilled nursing 

4 facility participating in the Program that 

5 has an agreement with the group practice 

6 for the furnishing of items and services 

7 identified under subsection (b)(3) to resi8 dents of the facility) shall be eligible to re9 ceive payment for shared savings under 

10 paragraph (2) only if the estimated aver11 age per capita Medicare expenditures for 

12 Medicare fee-for-service beneficiaries for 

13 parts A and B services furnished under the 

14 Program by the group practice (and any 

15 such facility), adjusted for beneficiary 

16 characteristics, is at least the percent spec17 ified by the Secretary below the applicable 

18 benchmark under clause (ii). The Sec19 retary shall determine the appropriate per20 cent described in the preceding sentence to 

21 account for normal variation in expendi22 tures under this title, based upon the num23 ber of Medicare fee-for-service beneficiaries 

24 participating in the Program. 


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1 ‘‘(ii) ESTABLISH AND UPDATE

2 BENCHMARK.—For each qualified group 

3 practice (and any qualified skilled nursing 

4 facility participating in the Program that 

5 has an agreement with the group practice 

6 for the furnishing of items and services 

7 identified under subsection (b)(3) to resi8 dents of the facility) the Secretary shall es9 timate a single benchmark for each year 

10 that is applicable to both the group prac11 tice (and any such facility) using the most 

12 recent available 3 years of per-beneficiary 

13 expenditures for parts A and B services for 

14 Medicare fee-for-service beneficiaries for 

15 items and services furnished by such group 

16 practice or skilled nursing facility under 

17 the Program. Such benchmark shall be ad18 justed for beneficiary characteristics and 

19 such other factors as the Secretary deter20 mines appropriate. Such benchmark shall 

21 be reset at the start of each year. 

22 ‘‘(2) PAYMENTS FOR SHARED SAVINGS.—If a 

23 qualified group practice (and any qualified skilled 

24 nursing facility participating in the Program that 

25 has an agreement with the group practice for the 


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1 furnishing of items and services identified under 

2 subsection (b)(3) to residents of the facility) meets 

3 the requirements under paragraph (1), the Secretary 

4 shall— 

5 ‘‘(A) pay to such qualified group practice 

6 an amount equal to 37.5 percent of the dif7 ference between such estimated average per 

8 capita Medicare expenditures in a year, ad9 justed for beneficiary characteristics, for items 

10 and services furnished under the Program by 

11 the group practice (and any such facility) and 

12 such benchmark for the qualified group practice 

13 (and any such facility); and 

14 ‘‘(B) in the case of each such facility— 

15 ‘‘(i) if the qualified skilled nursing fa16 cility has at least a three-star rating under 

17 the Five Star Quality Rating System (or a 

18 successor system), pay to the facility an 

19 amount that bears the same ratio to 12.5 

20 percent of the estimated amount of such 

21 difference as the amount of expenditures 

22 under the Program for such items and 

23 services furnished with respect to individ24 uals at such facility by such qualified 

25 group practice during such year bears to 


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1 the total amount of expenditures under the 

2 Program for such items and services fur3 nished with respect to all individuals by 

4 such qualified group practice during such 

5 year; and 

6 ‘‘(ii) in the case of a qualified skilled 

7 nursing facility that is not described in 

8 clause (i), retain in the Federal Hospital 

9 Insurance Trust Fund under section 1817 

10 the amount that the facility would have 

11 been paid pursuant to clause (i) if the fa12 cility were described in such clause until 

13 such time as the facility has at least a 

14 three-star rating under the Five Star Qual15 ity Rating System (or a successor system), 

16 at which point the Secretary shall pay such 

17 amount to the facility. 

18 ‘‘(3) ADVANCED ALTERNATIVE PAYMENT MOD19 ELS.—Paragraph (2) shall not apply to items and 

20 services furnished to an individual entitled to bene21 fits under part A and enrolled under Part B for 

22 whom shared savings would otherwise be attributed 

23 through an advanced alternative payment model as 

24 authorized under section 1115A or section 1899. 

25 ‘‘(e) EVALUATION.— 


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1 ‘‘(1) IN GENERAL.—With respect to a qualified 

2 group practice and a qualified skilled nursing facil3 ity, not later than 6 months after such group prac4 tice begins furnishing items and services under the 

5 Program (or, in the case of a qualified skilled nurs6 ing facility, not less than 6 months after a qualified 

7 group practice first furnishes such items and serv8 ices at such facility), and not less than once every 

9 2 years thereafter, the Secretary shall evaluate such 

10 qualified group practice and such qualified facility 

11 using information received under paragraph (2) on 

12 such criteria as determined appropriate by the Sec13 retary. 

14 ‘‘(2) REPORTING OF PERFORMANCE AND QUAL15 ITY IMPROVEMENTS.—In a time and manner speci16 fied by the Secretary, a qualified group practice and 

17 a qualified skilled nursing facility shall submit to the 

18 Secretary a report containing the following informa19 tion with respect to items and services furnished 

20 under the Program during a reporting period (as 

21 specified by the Secretary): 

22 ‘‘(A) The items and services most fre23 quently furnished under the Program in such 

24 period. 


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1 ‘‘(B) The number of individuals with re2 spect to whom such group practice furnished 

3 such items and services in such period (or, in 

4 the case of a qualified skilled nursing facility, 

5 the number of individuals with respect to whom 

6 such a group practice furnished such items and 

7 services at such facility in such period). 

8 ‘‘(C) The number of hospitalizations pre9 vented under the Program in such period. 

10 ‘‘(D) The number of such individuals who 

11 were admitted to a hospital or treated in the 

12 emergency department of a hospital within 24 

13 hours of being furnished such items and serv14 ices. 

15 ‘‘(E) Other information determined appro16 priate by the Secretary. 

17 ‘‘(3) LOSS OF QUALIFIED CERTIFICATION.— 

18 ‘‘(A) IN GENERAL.—Not later than 3 

19 months after a determination described in this 

20 sentence is made, the Secretary may revoke the 

21 certification of a qualified skilled nursing facil22 ity or a qualified group practice made under 

23 subsection (c) if— 

24 ‘‘(i) the Chief Actuary of the Centers 

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1 mines that the participation of such skilled 

2 nursing facility or such group practice in 

3 the Program during a year resulted in 

4 total expenditures under this title for such 

5 period being greater than total expendi6 tures under such title would have been 

7 during such period without such participa8 tion; or 

9 ‘‘(ii) a facility is selected for the Spe10 cial Focus Facility program or, if the facil11 ity is a candidate for the Special Focus 

12 Facility program, the Secretary determines 

13 that the participation of such facility in the 

14 Program should be terminated. 

15 ‘‘(B) EXCLUSION FROM CERTIFICATION.— 

16 ‘‘(i) IN GENERAL.—In the case that 

17 the Secretary revokes the certification of a 

18 qualified skilled nursing facility or a quali19 fied group practice under subparagraph 

20 (A), such skilled nursing facility or such 

21 group practice shall be ineligible for certifi22 cation as a qualified skilled nursing facility 

23 or a qualified group practice (as applica24 ble) under subsection (c) for the applicable 

25 period (as defined under clause (ii)). 


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1 ‘‘(ii) APPLICABLE PERIOD DE2 FINED.—In this subparagraph, the term 

3 ‘applicable period’ means— 

4 ‘‘(I) if the revocation of a facility 

5 or group practice under subparagraph 

6 (A) is due to the application of clause 

7 (i) of such subparagraph, a 1-year pe8 riod beginning on the date of such 

9 revocation; and 

10 ‘‘(II) in the revocation of a facil11 ity under subparagraph (A) is due to 

12 the application of clause (ii) of such 

13 subparagraph, the period beginning 

14 on the date of such revocation and 

15 ending on the date on which the facil16 ity graduates from the Special Focus 

17 Facility program (or, in the case of a 

18 facility that is a candidate for such 

19 program, the date on which the facil20 ity is no longer such a candidate, as 

21 determined by the Secretary). 

22 ‘‘(f) DETERMINATION OF BUDGET NEUTRALITY; 

23 TERMINATION OF PROGRAM.— 

24 ‘‘(1) DETERMINATION.—Not later than July 1, 

25 2027, the Chief Actuary of the Centers for Medicare 


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1 & Medicaid Services shall determine whether the 

2 Program has resulted in an increase in total expend3 itures under this title with respect to the period be4 ginning on January 1, 2022, and ending on Decem5 ber 31, 2026, compared to what such expenditures 

6 would have been during such period had the Pro7 gram not been in operation. 

8 ‘‘(2) TERMINATION.—If the Chief Actuary 

9 makes a determination under paragraph (1) that the 

10 Program has resulted in an increase in total expend11 itures under this title, the Secretary shall terminate 

12 the Program as of January 1 of the first year begin13 ning after such determination.’’. 

Æ 


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