I 

113TH CONGRESS 

2D SESSION H. R. 4762 

To amend title XVIII of the Social Security Act to cover transitional care 

services to improve the quality and cost effectiveness of care under 

the Medicare Program. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 29, 2014 

Mr. BLUMENAUER (for himself and Mr. PETRI) introduced the following bill; 

which was referred to the Committee on Energy and Commerce, and in 

addition to the Committee on Ways and Means, 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 cover 

transitional care services to improve the quality and cost 

effectiveness of care under the Medicare Program. 

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 Transitional 

5 Care Act of 2014’’. 

6 SEC. 2. FINDINGS. 

7 Congress finds the following: 


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1 (1) There are a number of care models that are 

2 designed to enhance coordination during transitions 

3 from care settings. 

4 (2) These care models and others have dem5 onstrated that effective care transitions lead to im6 provements in overall health care quality and result 

7 in savings to patients and the United States health 

8 care system. 

9 SEC. 3. MEDICARE COVERAGE OF TRANSITIONAL CARE 

10 SERVICES. 

11 (a) COVERAGE.—Section 1861 of the Social Security 

12 Act (42 U.S.C. 1395x) is amended— 

13 (1) in subsection (s)(2)— 

14 (A) by striking ‘‘and’’ at the end of sub15 paragraph (EE); 

16 (B) by adding ‘‘and’’ at the end of sub17 paragraph (FF); and 

18 (C) by inserting after subparagraph (FF) 

19 the following new subparagraph: 

20 ‘‘(GG) transitional care services (as defined in 

21 subsection (iii)(1));’’; and 

22 (2) by adding at the end the following new sub23 section: 


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1 ‘‘Transitional Care Services 

2 ‘‘(iii)(1) The term ‘transitional care services’ means 

3 services described in paragraph (2) furnished to a quali4 fied individual (described in paragraph (3)) by a transi5 tional care clinician (as defined in paragraph (4)) acting 

6 as an employee of (or pursuant to a contract with) a quali7 fied transitional care entity (as defined in paragraph (5)) 

8 during the transitional care period (as defined in para9 graph (6)) for the qualified individual. 

10 ‘‘(2) The services described in this paragraph are 

11 services that support a qualified individual during the 

12 transitional care period and include the following: 

13 ‘‘(A) A comprehensive assessment of the indi14 vidual prior to the individual’s transition from one 

15 care facility to another care facility or home, includ16 ing an assessment of the individual’s physical and 

17 mental condition, cognitive and functional capacities, 

18 medication regimen and adherence, social and envi19 ronmental needs, and primary caregiver needs and 

20 resources. 

21 ‘‘(B) Development of a comprehensive, evi22 denced-based plan of care for the individual devel23 oped with the individual and the individual’s primary 

24 caregiver and other health team members, identi25 fying potential health risks, treatment goals, current 


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1 therapies, and future services for both the individual 

2 and any primary caregiver. 

3 ‘‘(C) Development of a comprehensive medica4 tions management plan that ensures the safe use of 

5 medications and is based on the individual’s plan of 

6 care. Such management plan shall include the fol7 lowing: 

8 ‘‘(i) Identification of individual’s medica9 tions in use (including prescription and non10 prescription medications). 

11 ‘‘(ii) Assessment and (if needed) consulta12 tion with key medical providers to ensure medi13 cations are necessary, appropriate, and free of 

14 discrepancies. 

15 ‘‘(iii) Assessment of the individual and 

16 family caregiver’s health literacy regarding the 

17 ability to properly follow medication instruc18 tions. 

19 ‘‘(iv) Individual and family education and 

20 counseling about medications. 

21 ‘‘(v) Teaching and counseling the indi22 vidual and the individual’s primary caregiver 

23 (as appropriate) to assure adherence to medica24 tions and other therapies and avoid adverse 

25 events. 


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1 ‘‘(D) Implementation of a plan to facilitate the 

2 safe transition of the individual from one level of 

3 care, care setting, or provider to another, which 

4 transition plan shall include at least the following: 

5 ‘‘(i) A process to address the individual’s 

6 symptoms. 

7 ‘‘(ii) An established process for the indi8 vidual and family caregivers to receive timely 

9 access to key health care providers during an 

10 episode of care as required by the individual’s 

11 condition. 

12 ‘‘(iii) An established process for commu13 nicating with the individual, family caregivers, 

14 and other health care providers posttransition 

15 from an episode of care. 

16 ‘‘(iv) A system that ensures ownership, re17 sponsibility, and accountability for the care of 

18 the individual at all times, including identifying 

19 and documenting any family caregiver (or care20 givers) that exist. 

21 ‘‘(v) Providing information and resources 

22 about condition and care choices to adequately 

23 prepare the individual and caregivers for in24 formed decisionmaking. 


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1 ‘‘(E) Providing to the qualified individual, pri2 mary caregiver, and appropriate clinicians and the 

3 qualified transitional care entity providing ongoing 

4 care at the conclusion of the transitional care period, 

5 a written summary that includes the goals estab6 lished in the plan of care described in subparagraph 

7 (B), progress in achieving such goals, and remaining 

8 treatment needs. 

9 ‘‘(F) Other services that the Secretary deter10 mines are appropriate. 

11 The Secretary shall determine and update from time to 

12 time the services to be included in transitional care serv13 ices as appropriate, based on the evidence of their effec14 tiveness in reducing hospital readmissions and improving 

15 health outcomes. 

16 ‘‘(3)(A) In this subsection, subject to subparagraph 

17 (C), the term ‘qualified individual’ means an individual 

18 who— 

19 ‘‘(i) has been admitted to a subsection (d) hos20 pital (as defined for purposes of section 1886) for 

21 inpatient hospital services or to a critical care hos22 pital for inpatient critical access hospital services; 

23 and 


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1 ‘‘(ii) is identified by the Secretary as being at 

2 highest risk for readmission or for a poor transition 

3 from such a hospital to a posthospital site of care. 

4 ‘‘(B) The identification under subparagraph (A)(ii) 

5 shall be based on achieving a minimum hierarchical condi6 tion category score (specified by the Secretary) in order 

7 to target eligibility benefits under this subsection to indi8 viduals with multiple chronic conditions and other risk fac9 tors, such as cognitive impairment, depression, or a his10 tory of multiple hospitalizations. 

11 ‘‘(C) After submitting to Congress the evaluation 

12 under section 2(d) of the Medicare Transitional Care Act 

13 of 2014 and considering any cost savings and quality im14 provements from the prior implementation of transitional 

15 care services under this title, the Secretary may expand 

16 eligibility of qualified individuals to include moderate-risk 

17 and lower-risk individuals, as determined in accordance 

18 with eligibility criteria specified by the Secretary. In ex19 panding eligibility, the Secretary may modify or scale 

20 transitional care services to meet the specific needs of 

21 moderate-risk and lower-risk individuals. 

22 ‘‘(D) The Secretary shall ensure that qualified indi23 viduals receiving transitional care services are not receiv24 ing duplicative services under this title. 


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1 ‘‘(4)(A) The term ‘transitional care clinician’ means, 

2 with respect to a qualified individual, a nurse, case man3 ager, social worker, physician assistant, physician, phar4 macist, or other licensed health professional who— 

5 ‘‘(i) has received specialized training in the clin6 ical care of people with multiple chronic conditions 

7 (including medication management) and communica8 tion and coordination with multiple providers of 

9 services, suppliers, patients, and their primary care10 givers; 

11 ‘‘(ii) is supported by an interdisciplinary team 

12 in a manner that assures continuity of care through13 out a transitional care period and across care set14 tings (including the residences of qualified individ15 uals); 

16 ‘‘(iii) is employed by (or has a contract with) a 

17 qualified transitional care entity for the furnishing 

18 of transitional care services; and 

19 ‘‘(iv) meets such participation criteria as the 

20 Secretary may specify consistent with this sub21 section. 

22 ‘‘(B) In establishing participation criteria under sub23 paragraph (A)(iv), the Secretary shall assure that transi24 tional care clinicians meet relevant scope of practice and 


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1 training requirements and have the ability to meet the in2 dividual needs of qualified individuals. 

3 ‘‘(5) The term ‘qualified transitional care entity’ 

4 means— 

5 ‘‘(A) a hospital or a critical care hospital; 

6 ‘‘(B) a home health agency; 

7 ‘‘(C) a primary care practice; 

8 ‘‘(D) a federally qualified health center or rural 

9 health clinic; 

10 ‘‘(E) a long-term care facility; 

11 ‘‘(F) a medical home; 

12 ‘‘(G) an appropriate community-based organiza13 tion described in section 3026(b)(1)(B) of the Pa14 tient Protection and Affordable Care Act (42 U.S.C. 

15 1395b–1 note); 

16 ‘‘(H) an assisted living center; 

17 ‘‘(I) an accountable care organization; and 

18 ‘‘(J) another entity approved by the Secretary 

19 for purposes of this subsection. 

20 ‘‘(6) The term ‘transitional care period’ means, with 

21 respect to a qualified individual, the period— 

22 ‘‘(A) beginning on the date the individual is ad23 mitted to a subsection (d) hospital (as defined for 

24 purposes of section 1886) for inpatient hospital serv25 ices or is admitted to a critical care hospital for inVerDate Mar 15 2010 03:30 Jun 04, 2014 Jkt 039200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H4762.IH H4762

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1 patient critical access hospital services, for which 

2 payment may be made under this title; and 

3 ‘‘(B) ending on the last day of the 45-day pe4 riod beginning on the date of the individual’s dis5 charge from such hospital or critical care hospital.’’. 

6 (b) PAYMENT AND PERFORMANCE MEASURES.—Sec7 tion 1833 of the Social Security Act (42 U.S.C. 1395l) 

8 is amended— 

9 (1) in subsection (a)(1), by striking ‘‘and’’ be10 fore ‘‘(Z)’’ and by inserting before the semicolon at 

11 the end the following: ‘‘, and (AA) with respect to 

12 transitional care services (as defined in section 

13 1861(iii)(1)), the amounts paid shall be 100 percent 

14 of the amount determined under subsection (z)’’; 

15 (2) in the first sentence of subsection (b), by in16 serting ‘‘or transitional care services (as defined in 

17 section 1861(iii)(1))’’ after ‘‘(as defined in section 

18 1861(hh)(1))’’; and 

19 (3) by adding at the end the following new sub20 section: 

21 ‘‘(z) PAYMENT AND PERFORMANCE MEASURES FOR

22 TRANSITIONAL CARE SERVICES.— 

23 ‘‘(1) PAYMENT.— 

24 ‘‘(A) IN GENERAL.—The Secretary shall 

25 determine the method of payment for transiVerDate Mar 15 2010 03:30 Jun 04, 2014 Jkt 039200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H4762.IH H4762

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1 tional care services under this part, including 

2 appropriate risk adjustment that reflects the 

3 differences in resources needed to provide tran4 sitional care services to individuals with dif5 fering characteristics and circumstances and, 

6 when applicable, the performance measures 

7 under paragraph (3). The payment amount 

8 shall be sufficient to ensure the provision of 

9 necessary transitional care services throughout 

10 the transitional care period. The payment shall 

11 be structured in a manner to explicitly recog12 nize transitional care as an episode of services 

13 that crosses multiple care settings, providers of 

14 services, and suppliers. The payment with re15 spect to transitional care services furnished by 

16 a transitional care clinician shall be made, not17 withstanding any other provision of this title, to 

18 the qualified transitional care entity which em19 ploys, or has a contract with, the clinician for 

20 the furnishing of such services. 

21 ‘‘(B) HIT INCENTIVE PAYMENT.—The 

22 Secretary may provide for an additional pay23 ment with respect to transitional care services 

24 to encourage transitional care clinicians and 

25 qualified transitional care entities to use health 


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1 information technology in the provision of such 

2 services. 

3 ‘‘(C) NO PAYMENT FOR REQUIRED DIS4 CHARGE PLANNING SERVICES.—Payment shall 

5 not be made for transitional care services under 

6 this subsection for an entity insofar as such 

7 services are otherwise required to be provided 

8 through the discharge planning process under 

9 section 1861(ee) or under conditions of partici10 pation for the entity under section 1866. 

11 ‘‘(2) PERFORMANCE MEASURES.— 

12 ‘‘(A) ACCOUNTABILITY.— 

13 ‘‘(i) IN GENERAL.—The Secretary 

14 shall establish a method whereby qualified 

15 transitional care entities responsible for 

16 furnishing transitional care services are 

17 held accountable for process and outcome 

18 based on performance measures specified 

19 by the Secretary from those that have been 

20 endorsed by the National Quality Forum 

21 or similar standard-setting organization or 

22 are otherwise used in other quality pro23 grams under this title or title XIX. 

24 ‘‘(ii) DEVELOPMENT AND ENDORSE25 MENT OF PERFORMANCE MEASURE SET.— 


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1 For purposes of carrying out clause (i), the 

2 Secretary shall enter into an arrange3 ment— 

4 ‘‘(I) with the National Quality 

5 Forum for the evaluation, endorse6 ment, and recommendation of addi7 tional performance measures for tran8 sitional care services and to identify 

9 remaining gaps in available measures, 

10 including measures to both the send11 ing and receiving side of the transi12 tion; and 

13 ‘‘(II) with the Agency for 

14 Healthcare Research and Quality to 

15 support measure development, to fill 

16 gaps in available measures, to conduct 

17 comparative effectiveness research of 

18 transitional care models and tools, 

19 and to provide for the ongoing main20 tenance of the set of performance 

21 measures for transitional care serv22 ices. 

23 ‘‘(B) PAY FOR PERFORMANCE.—As soon 

24 as practicable after reliable process and out25 come performance measures have been endorsed 


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1 and specified under subparagraph (A), the Sec2 retary shall provide that the payment amounts 

3 under paragraph (1) for transitional care serv4 ices shall be linked to performance on such 

5 measures. 

6 ‘‘(C) PUBLIC REPORTING.—The Secretary 

7 shall establish a mechanism to publicly report 

8 on a qualifying transitional care entity’s per9 formance on such measures, including providing 

10 benchmarks to identify high performers and 

11 those practices that contribute to lower hospital 

12 readmission rates. 

13 ‘‘(D) DISSEMINATION OF INFORMATION ON

14 BEST PRACTICES.—The Secretary shall dissemi15 nate information on best practices used by tran16 sitional care clinicians and qualified transitional 

17 care entities in furnishing transitional care 

18 services for purposes of application in other set19 tings, such as in conditions of participation 

20 under this title, under the Quality Improvement 

21 Organization Program under part B of title XI, 

22 and public-private quality alliances, such as the 

23 Hospital Quality Alliance. 

24 ‘‘(3) PREVENTION OF INAPPROPRIATE STEER25 ING.—The Secretary shall promulgate such regulaVerDate Mar 15 2010 03:30 Jun 04, 2014 Jkt 039200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\H4762.IH H4762

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1 tions as the Secretary deems necessary to address 

2 any protections needed, beyond those otherwise pro3 vided under law and regulations, to prevent inappro4 priate steering of qualified individuals to providers 

5 of services, suppliers, qualified transitional care enti6 ties, or transitional care clinicians, under this part 

7 or inappropriate limitations on access to needed 

8 transitional care services under this part.’’. 

9 (c) COORDINATION WITH HOSPITAL DISCHARGE

10 PLANNING.—Section 1861(ee)(2) of the Social Security 

11 Act (42 U.S.C. 1395x(ee)(2)) is amended by adding at 

12 the end the following: 

13 ‘‘(I) In the case of subsection (d) hospitals 

14 and critical care hospitals, the hospital must— 

15 ‘‘(i) identify, as soon as practicable 

16 after admission, those patients who are 

17 qualified individuals described in para18 graph (3) of section 1861(iii); and 

19 ‘‘(ii) provide to such patients and 

20 their primary caregivers a list of transi21 tional care entities available under such 

22 section to arrange for the provision of 

23 transitional care services, a list of transi24 tional care services provided under this 

25 part, and a notice that the transitional 


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1 care service benefit under such section is 

2 provided to qualified individuals with no 

3 deductible or cost sharing. 

4 Nothing in subparagraph (I) shall be construed 

5 as preventing a hospital or critical care hospital 

6 from entering into an agreement with a quali7 fied transitional care entity or a transitional 

8 care clinician for the furnishing of transitional 

9 care services to the hospital’s patients.’’. 

10 (d) EVALUATION; REPORT.— 

11 (1) IN GENERAL.—The Secretary of Health and 

12 Human Services shall evaluate the performance of 

13 the transitional care benefit under the amendments 

14 made by this section by measuring the following, 

15 both for individuals receiving transitional care serv16 ices and for individuals not receiving such services: 

17 (A) Admission rates to health care facili18 ties. 

19 (B) Hospital readmission rates. 

20 (C) Cost of transitional care and all other 

21 health care services. 

22 (D) Quality of transitional care experi23 ences. 

24 (E) Measures of quality and efficiency. 

25 (F) Beneficiary experience. 


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1 (G) Health outcomes. 

2 (H) Reductions in expenditures under this 

3 title over time. 

4 (2) REPORT.—The Secretary shall submit a re5 port to Congress no later than April 1, 2018, on the 

6 performance measures achieved by the transitional 

7 care benefit in the first 2 years of implementation. 

8 After submitting such report, the Secretary may ex9 pand the benefit to moderate-risk and lower-risk in10 dividuals under section 1861(iii)(3)(B) of the Social 

11 Security Act, as added by subsection (a). 

12 (e) EFFECTIVE DATE.—The amendments made by 

13 this section shall apply to services furnished on or after 

14 January 1, 2015. 

Æ 


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