H. R. 4994 

One Hundred Thirteenth Congress 

of the 

United States of America 

AT THE SECOND SESSION 

Begun and held at the City of Washington on Friday, 

the third day of January, two thousand and fourteen 

An Act 

To amend title XVIII of the Social Security Act to provide for standardized postacute care assessment data for quality, payment, and discharge planning, and 

for other purposes. 

Be it enacted by the Senate and House of Representatives of 

the United States of America in Congress assembled, 

SECTION 1. SHORT TITLE. 

This Act may be cited as the ‘‘Improving Medicare Post-Acute 

Care Transformation Act of 2014’’ or the ‘‘IMPACT Act of 2014’’. 

SEC. 2. STANDARDIZATION OF POST-ACUTE CARE DATA. 

(a) IN GENERAL.—Title XVIII of the Social Security Act is 

amended by adding at the end the following new section: 

‘‘SEC. 1899B. STANDARDIZED POST-ACUTE CARE (PAC) ASSESSMENT 

DATA FOR QUALITY, PAYMENT, AND DISCHARGE PLANNING. 

‘‘(a) REQUIREMENT FOR STANDARDIZED ASSESSMENT DATA.— 

‘‘(1) IN GENERAL.—The Secretary shall— 

‘‘(A) require under the applicable reporting provisions 

post-acute care providers (as defined in paragraph (2)(A)) 

to report— 

‘‘(i) standardized patient assessment data in 

accordance with subsection (b); 

‘‘(ii) data on quality measures under subsection 

(c)(1); and 

‘‘(iii) data on resource use and other measures 

under subsection (d)(1); 

‘‘(B) require data described in subparagraph (A) to 

be standardized and interoperable so as to allow for the 

exchange of such data among such post-acute care providers 

and other providers and the use by such providers of such 

data that has been so exchanged, including by using 

common standards and definitions, in order to provide 

access to longitudinal information for such providers to 

facilitate coordinated care and improved Medicare beneficiary outcomes; and 

‘‘(C) in accordance with subsections (b)(1) and (c)(2), 

modify PAC assessment instruments (as defined in paragraph (2)(B)) applicable to post-acute care providers to— 

‘‘(i) provide for the submission of standardized 

patient assessment data under this title with respect 

to such providers; and 
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‘‘(ii) enable comparison of such assessment data 

across all such providers to whom such data are 

applicable. 

‘‘(2) DEFINITIONS.—For purposes of this section: 

‘‘(A) POST-ACUTE CARE (PAC) PROVIDER.—The terms 

‘post-acute care provider’ and ‘PAC provider’ mean— 

‘‘(i) a home health agency; 

‘‘(ii) a skilled nursing facility; 

‘‘(iii) an inpatient rehabilitation facility; and 

‘‘(iv) a long-term care hospital (other than a hospital classified under section 1886(d)(1)(B)(iv)(II)). 

‘‘(B) PAC ASSESSMENT INSTRUMENT.—The term ‘PAC 

assessment instrument’ means— 

‘‘(i) in the case of home health agencies, the 

instrument used for purposes of reporting and assessment with respect to the Outcome and Assessment 

Information Set (OASIS), as described in sections 

484.55 and 484.250 of title 42, the Code of Federal 

Regulations, or any successor regulation, or any other 

instrument used with respect to home health agencies 

for such purposes; 

‘‘(ii) in the case of skilled nursing facilities, the 

resident’s assessment under section 1819(b)(3); 

‘‘(iii) in the case of inpatient rehabilitation facilities, any Medicare beneficiary assessment instrument 

established by the Secretary for purposes of section 

1886(j); and 

‘‘(iv) in the case of long-term care hospitals, the 

Medicare beneficiary assessment instrument used with 

respect to such hospitals for the collection of data 

elements necessary to calculate quality measures as 

described in the August 18, 2011, Federal Register 

(76 Fed. Reg. 51754–51755), including for purposes 

of section 1886(m)(5)(C), or any other instrument used 

with respect to such hospitals for assessment purposes. 

‘‘(C) APPLICABLE REPORTING PROVISION.—The term 

‘applicable reporting provision’ means— 

‘‘(i) for home health agencies, section 

1895(b)(3)(B)(v); 

‘‘(ii) for skilled nursing facilities, section 1888(e)(6); 

‘‘(iii) for inpatient rehabilitation facilities, section 

1886(j)(7); and 

‘‘(iv) for long-term care hospitals, section 

1886(m)(5). 

‘‘(D) PAC PAYMENT SYSTEM.—The term ‘PAC payment 

system’ means— 

‘‘(i) with respect to a home health agency, the 

prospective payment system under section 1895; 

‘‘(ii) with respect to a skilled nursing facility, the 

prospective payment system under section 1888(e); 

‘‘(iii) with respect to an inpatient rehabilitation 

facility, the prospective payment system under section 

1886(j); and 

‘‘(iv) with respect to a long-term care hospital, 

the prospective payment system under section 1886(m). 

‘‘(E) SPECIFIED APPLICATION DATE.—The term ‘specified 

application date’ means the following: 
H. R. 4994—3 

‘‘(i) QUALITY MEASURES.—In the case of quality 

measures under subsection (c)(1)— 

‘‘(I) with respect to the domain described in 

subsection (c)(1)(A) (relating to functional status, 

cognitive function, and changes in function and 

cognitive function)— 

‘‘(aa) for PAC providers described in 

clauses (ii) and (iii) of paragraph (2)(A), 

October 1, 2016; 

‘‘(bb) for PAC providers described in clause 

(iv) of such paragraph, October 1, 2018; and 

‘‘(cc) for PAC providers described in clause 

(i) of such paragraph, January 1, 2019; 

‘‘(II) with respect to the domain described in 

subsection (c)(1)(B) (relating to skin integrity and 

changes in skin integrity)— 

‘‘(aa) for PAC providers described in 

clauses (ii), (iii), and (iv) of paragraph (2)(A), 

October 1, 2016; and 

‘‘(bb) for PAC providers described in clause 

(i) of such paragraph, January 1, 2017; 

‘‘(III) with respect to the domain described 

in subsection (c)(1)(C) (relating to medication reconciliation)— 

‘‘(aa) for PAC providers described in clause 

(i) of such paragraph, January 1, 2017; and 

‘‘(bb) for PAC providers described in 

clauses (ii), (iii), and (iv) of such paragraph, 

October 1, 2018; 

‘‘(IV) with respect to the domain described in 

subsection (c)(1)(D) (relating to incidence of major 

falls)— 

‘‘(aa) for PAC providers described in 

clauses (ii), (iii), and (iv) of paragraph (2)(A), 

October 1, 2016; and 

‘‘(bb) for PAC providers described in clause 

(i) of such paragraph, January 1, 2019; and 

‘‘(V) with respect to the domain described in 

subsection (c)(1)(E) (relating to accurately communicating the existence of and providing for the 

transfer of health information and care preferences)— 

‘‘(aa) for PAC providers described in 

clauses (ii), (iii), and (iv) of paragraph (2)(A), 

October 1, 2018; and 

‘‘(bb) for PAC providers described in clause 

(i) of such paragraph, January 1, 2019. 

‘‘(ii) RESOURCE USE AND OTHER MEASURES.—In the 

case of resource use and other measures under subsection (d)(1)— 

‘‘(I) for PAC providers described in clauses 

(ii), (iii), and (iv) of paragraph (2)(A), October 1, 

2016; and 

‘‘(II) for PAC providers described in clause (i) 

of such paragraph, January 1, 2017. 

‘‘(F) MEDICARE BENEFICIARY.—The term ‘Medicare 

beneficiary’ means an individual entitled to benefits under 
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part A or, as appropriate, enrolled for benefits under part 

B. 

‘‘(b) STANDARDIZED PATIENT ASSESSMENT DATA.— 

‘‘(1) REQUIREMENT FOR REPORTING ASSESSMENT DATA.— 

‘‘(A) IN GENERAL.—Beginning not later than October 

1, 2018, for PAC providers described in clauses (ii), (iii), 

and (iv) of subsection (a)(2)(A) and January 1, 2019, for 

PAC providers described in clause (i) of such subsection, 

the Secretary shall require PAC providers to submit to 

the Secretary, under the applicable reporting provisions 

and through the use of PAC assessment instruments, the 

standardized patient assessment data described in subparagraph (B). The Secretary shall require such data be submitted with respect to admission and discharge of an individual (and may be submitted more frequently as the Secretary deems appropriate). 

‘‘(B) STANDARDIZED PATIENT ASSESSMENT DATA

DESCRIBED.—For purposes of subparagraph (A), the 

standardized patient assessment data described in this 

subparagraph is data required for at least the quality measures described in subsection (c)(1) and that is with respect 

to the following categories: 

‘‘(i) Functional status, such as mobility and self 

care at admission to a PAC provider and before discharge from a PAC provider. 

‘‘(ii) Cognitive function, such as ability to express 

ideas and to understand, and mental status, such as 

depression and dementia. 

‘‘(iii) Special services, treatments, and interventions, such as need for ventilator use, dialysis, chemotherapy, central line placement, and total parenteral 

nutrition. 

‘‘(iv) Medical conditions and co-morbidities, such 

as diabetes, congestive heart failure, and pressure 

ulcers. 

‘‘(v) Impairments, such as incontinence and an 

impaired ability to hear, see, or swallow. 

‘‘(vi) Other categories deemed necessary and appropriate by the Secretary. 

‘‘(2) ALIGNMENT OF CLAIMS DATA WITH STANDARDIZED

PATIENT ASSESSMENT DATA.—To the extent practicable, not later 

than October 1, 2018, for PAC providers described in clauses 

(ii), (iii), and (iv) of subsection (a)(2)(A), and January 1, 2019, 

for PAC providers described in clause (i) of such subsection, 

the Secretary shall match claims data with assessment data 

pursuant to this section for purposes of assessing prior service 

use and concurrent service use, such as antecedent hospital 

or PAC provider use, and may use such matched data for 

such other uses as the Secretary determines appropriate. 

‘‘(3) REPLACEMENT OF CERTAIN EXISTING DATA.—In the case 

of patient assessment data being used with respect to a PAC 

assessment instrument that duplicates or overlaps with 

standardized patient assessment data within a category 

described in paragraph (1), the Secretary shall, as soon as 

practicable, revise or replace such existing data with the 

standardized data. 
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‘‘(4) CLARIFICATION.—Standardized patient assessment data 

submitted pursuant to this subsection shall not be used to 

require individuals to be provided post-acute care by a specific 

type of PAC provider in order for such care to be eligible 

for payment under this title. 

‘‘(c) QUALITY MEASURES.— 

‘‘(1) REQUIREMENT FOR REPORTING QUALITY MEASURES.— 

Not later than the specified application date, as applicable 

to measures and PAC providers, the Secretary shall specify 

quality measures on which PAC providers are required under 

the applicable reporting provisions to submit standardized 

patient assessment data described in subsection (b)(1) and other 

necessary data specified by the Secretary. Such measures shall 

be with respect to at least the following domains: 

‘‘(A) Functional status, cognitive function, and changes 

in function and cognitive function. 

‘‘(B) Skin integrity and changes in skin integrity. 

‘‘(C) Medication reconciliation. 

‘‘(D) Incidence of major falls. 

‘‘(E) Accurately communicating the existence of and 

providing for the transfer of health information and care 

preferences of an individual to the individual, family caregiver of the individual, and providers of services furnishing 

items and services to the individual, when the individual 

transitions— 

‘‘(i) from a hospital or critical access hospital to 

another applicable setting, including a PAC provider 

or the home of the individual; or 

‘‘(ii) from a PAC provider to another applicable 

setting, including a different PAC provider, a hospital, 

a critical access hospital, or the home of the individual. 

‘‘(2) REPORTING THROUGH PAC ASSESSMENT INSTRUMENTS.— 

‘‘(A) IN GENERAL.—To the extent possible, the Secretary 

shall require such reporting by a PAC provider of quality 

measures under paragraph (1) through the use of a PAC 

assessment instrument and shall modify such PAC assessment instrument as necessary to enable the use of such 

instrument with respect to such quality measures. 

‘‘(B) LIMITATION.—The Secretary may not make significant modifications to a PAC assessment instrument more 

than once per calendar year or fiscal year, as applicable, 

unless the Secretary publishes in the Federal Register a 

justification for such significant modification. 

‘‘(3) ADJUSTMENTS.— 

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

applying adjustments to the quality measures under this 

subsection taking into consideration the studies under section 2(d) of the IMPACT Act of 2014. 

‘‘(B) RISK ADJUSTMENT.—Such quality measures shall 

be risk adjusted, as determined appropriate by the Secretary. 

‘‘(d) RESOURCE USE AND OTHER MEASURES.— ‘‘(1) REQUIREMENT FOR RESOURCE USE AND OTHER MEAS- URES.—Not later than the specified application date, as 

applicable to measures and PAC providers, the Secretary shall 

specify resource use and other measures on which PAC providers are required under the applicable reporting provisions 
H. R. 4994—6 

to submit any necessary data specified by the Secretary, which 

may include standardized assessment data in addition to claims 

data. Such measures shall be with respect to at least the 

following domains: 

‘‘(A) Resource use measures, including total estimated 

Medicare spending per beneficiary. 

‘‘(B) Discharge to community. 

‘‘(C) Measures to reflect all-condition risk-adjusted 

potentially preventable hospital readmission rates. 

‘‘(2) ALIGNING METHODOLOGY ADJUSTMENTS FOR RESOURCE

USE MEASURES.— 

‘‘(A) PERIOD OF TIME.—With respect to the period of 

time used for calculating measures under paragraph (1)(A), 

the Secretary shall, to the extent the Secretary determines 

appropriate, align resource use with the methodology used 

for purposes of section 1886(o)(2)(B)(ii). 

‘‘(B) GEOGRAPHIC AND OTHER ADJUSTMENTS.—The Secretary shall standardize measures with respect to the 

domain described in paragraph (1)(A) for geographic payment rate differences and payment differentials (and other 

adjustments, as applicable) consistent with the methodology published in the Federal Register on August 18, 

2011 (76 Fed. Reg. 51624 through 51626), or any subsequent modifications made to the methodology. 

‘‘(C) MEDICARE SPENDING PER BENEFICIARY.—The Secretary shall adjust, as appropriate, measures with respect 

to the domain described in paragraph (1)(A) for the factors 

applied under section 1886(o)(2)(B)(ii). 

‘‘(3) ADJUSTMENTS.— 

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

applying adjustments to the resource use and other measures specified under this subsection with respect to the 

domain described in paragraph (1)(A), taking into consideration the studies under section 2(d) of the IMPACT Act 

of 2014. 

‘‘(B) RISK ADJUSTMENT.—Such resource use and other 

measures shall be risk adjusted, as determined appropriate 

by the Secretary. 

‘‘(e) MEASUREMENT IMPLEMENTATION PHASES; SELECTION OF

QUALITY MEASURES AND RESOURCE USE AND OTHER MEASURES.— 

‘‘(1) MEASUREMENT IMPLEMENTATION PHASES.—In the case 

of quality measures specified under subsection (c)(1) and 

resource use and other measures specified under subsection 

(d)(1), the provisions of this section shall be implemented in 

accordance with the following phases: 

‘‘(A) INITIAL IMPLEMENTATION PHASE.—The initial 

implementation phase, with respect to such a measure, 

shall, in accordance with subsections (c) and (d), as 

applicable, consist of— 

‘‘(i) measure specification, including informing the 

public of the measure’s numerator, denominator, exclusions, and any other aspects the Secretary determines 

necessary; 

‘‘(ii) data collection, including, in the case of quality 

measures, requiring PAC providers to report data elements needed to calculate such a measure; and 
H. R. 4994—7 

‘‘(iii) data analysis, including, in the case of 

resource use and other measures, the use of claims 

data to calculate such a measure. 

‘‘(B) SECOND IMPLEMENTATION PHASE.—The second 

implementation phase, with respect to such a measure, 

shall consist of the provision of feedback reports to PAC 

providers, in accordance with subsection (f). 

‘‘(C) THIRD IMPLEMENTATION PHASE.—The third 

implementation phase, with respect to such a measure, 

shall consist of public reporting of PAC providers’ performance on such measure in accordance with subsection (g). 

‘‘(2) CONSENSUS-BASED ENTITY.— 

‘‘(A) IN GENERAL.—Subject to subparagraph (B), each 

measure specified by the Secretary under this section shall 

be endorsed by the entity with a contract under section 

1890(a). 

‘‘(B) EXCEPTION.—In the case of a specified area or 

medical topic determined appropriate by the Secretary for 

which a feasible and practical measure has not been 

endorsed by the entity with a contract under section 

1890(a), the Secretary may specify a measure that is not 

so endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus 

organization identified by the Secretary. 

‘‘(3) TREATMENT OF APPLICATION OF PRE-RULEMAKING

PROCESS (MEASURE APPLICATIONS PARTNERSHIP PROCESS).— 

‘‘(A) IN GENERAL.—Subject to subparagraph (B), the 

provisions of section 1890A shall apply in the case of a 

quality measure specified under subsection (c) or a resource 

use or other measure specified under subsection (d). 

‘‘(B) EXCEPTIONS.— 

‘‘(i) EXPEDITED PROCEDURES.—For purposes of 

satisfying subparagraph (A), the Secretary may use 

expedited procedures, such as ad-hoc reviews, as necessary, in the case of a quality measure specified under 

subsection (c) or a resource use or other measure specified in subsection (d) required with respect to data 

submissions under the applicable reporting provisions 

during the 1-year period before the specified application date applicable to such a measure and provider 

involved. 

‘‘(ii) OPTION TO WAIVE PROVISIONS.—The Secretary 

may waive the application of the provisions of section 

1890A in the case of a quality measure or resource 

use or other measure described in clause (i), if the 

application of such provisions (including through the 

use of an expedited procedure described in such clause) 

would result in the inability of the Secretary to satisfy 

any deadline specified in this section with respect to 

such measure. 

‘‘(f) FEEDBACK REPORTS TO PAC PROVIDERS.— 

‘‘(1) IN GENERAL.—Beginning one year after the specified 

application date, as applicable to PAC providers and quality 

measures and resource use and other measures under this 

section, the Secretary shall provide confidential feedback 

reports to such PAC providers on the performance of such 
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providers with respect to such measures required under the 

applicable provisions. 

‘‘(2) FREQUENCY.—To the extent feasible, the Secretary 

shall provide feedback reports described in paragraph (1) not 

less frequently than on a quarterly basis. Notwithstanding 

the previous sentence, with respect to measures described in 

such paragraph that are reported on an annual basis, the 

Secretary may provide such feedback reports on an annual 

basis. 

‘‘(g) PUBLIC REPORTING OF PAC PROVIDER PERFORMANCE.— ‘‘(1) IN GENERAL.—Subject to the succeeding paragraphs 

of this subsection, the Secretary shall provide for public 

reporting of PAC provider performance on quality measures 

under subsection (c)(1) and the resource use and other measures 

under subsection (d)(1), including by establishing procedures 

for making available to the public information regarding the 

performance of individual PAC providers with respect to such 

measures. 

‘‘(2) OPPORTUNITY TO REVIEW.—The procedures under paragraph (1) shall ensure, including through a process consistent 

with the process applied under section 1886(b)(3)(B)(viii)(VII) 

for similar purposes, that a PAC provider has the opportunity 

to review and submit corrections to the data and information 

that is to be made public with respect to the provider prior 

to such data being made public. 

‘‘(3) TIMING.—Such procedures shall provide that the data 

and information described in paragraph (1), with respect to 

a measure and PAC provider, is made publicly available beginning not later than two years after the specified application 

date applicable to such a measure and provider. 

‘‘(4) COORDINATION WITH EXISTING PROGRAMS.—Such procedures shall provide that data and information described in 

paragraph (1) with respect to quality measures and resource 

use and other measures under subsections (c)(1) and (d)(1) 

shall be made publicly available consistent with the following 

provisions: 

‘‘(A) In the case of home health agencies, section 

1895(b)(3)(B)(v)(III). 

‘‘(B) In the case of skilled nursing facilities, sections 

1819(i) and 1919(i). 

‘‘(C) In the case of inpatient rehabilitation facilities, 

section 1886(j)(7)(E). 

‘‘(D) In the case of long-term care hospitals, section 

1886(m)(5)(E). 

‘‘(h) REMOVING, SUSPENDING, OR ADDING MEASURES.— 

‘‘(1) IN GENERAL.—The Secretary may remove, suspend, 

or add a quality measure or resource use or other measure 

described in subsection (c)(1) or (d)(1), so long as, subject to 

paragraph (2), the Secretary publishes in the Federal Register 

(with a notice and comment period) a justification for such 

removal, suspension, or addition. 

‘‘(2) EXCEPTION.—In the case of such a quality measure 

or resource use or other measure for which there is a reason 

to believe that the continued collection of such measure raises 

potential safety concerns or would cause other unintended consequences, the Secretary may promptly suspend or remove 

such measure and satisfy paragraph (1) by publishing in the 
H. R. 4994—9 

Federal Register a justification for such suspension or removal 

in the next rulemaking cycle following such suspension or 

removal. 

‘‘(i) USE OF STANDARDIZED ASSESSMENT DATA, QUALITY MEASURES, AND RESOURCE USE AND OTHER MEASURES TO INFORM DISCHARGE PLANNING AND INCORPORATE PATIENT PREFERENCE.— 

‘‘(1) IN GENERAL.—Not later than January 1, 2016, and 

periodically thereafter (but not less frequently than once every 

5 years), the Secretary shall promulgate regulations to modify 

conditions of participation and subsequent interpretive guidance applicable to PAC providers, hospitals, and critical access 

hospitals. Such regulations and interpretive guidance shall 

require such providers to take into account quality, resource 

use, and other measures under the applicable reporting provisions (which, as available, shall include measures specified 

under subsections (c) and (d), and other relevant measures) 

in the discharge planning process. Specifically, such regulations 

and interpretive guidance shall address the settings to which 

a patient may be discharged in order to assist subsection (d) 

hospitals, critical access hospitals, hospitals described in section 

1886(d)(1)(B)(v), PAC providers, patients, and families of such 

patients with discharge planning from inpatient settings, 

including such hospitals, and from PAC provider settings. In 

addition, such regulations and interpretive guidance shall 

include procedures to address— 

‘‘(A) treatment preferences of patients; and 

‘‘(B) goals of care of patients. 

‘‘(2) DISCHARGE PLANNING.—All requirements applied 

pursuant to paragraph (1) shall be used to help inform and 

mandate the discharge planning process. 

‘‘(3) CLARIFICATION.—Such regulations shall not require an 

individual to be provided post-acute care by a specific type 

of PAC provider in order for such care to be eligible for payment 

under this title. 

‘‘(j) STAKEHOLDER INPUT.—Before the initial rulemaking process 

to implement this section, the Secretary shall allow for stakeholder 

input, such as through town halls, open door forums, and mailbox submissions. 

‘‘(k) FUNDING.—For purposes of carrying out this section, the 

Secretary shall provide for the transfer to the Centers for Medicare 

& Medicaid Services Program Management Account, from the Federal Hospital Insurance Trust Fund under section 1817 and the 

Federal Supplementary Medical Insurance Trust Fund under section 1841, in such proportion as the Secretary determines appropriate, of $130,000,000. Fifty percent of such amount shall be available on the date of the enactment of this section and fifty percent 

of such amount shall be equally proportioned for each of fiscal 

years 2015 through 2019. Such sums shall remain available until 

expended. 

‘‘(l) LIMITATION.—There shall be no administrative or judicial 

review under sections 1869 and 1878 or otherwise of the specification of standardized patient assessment data required, the determination of measures, and the systems to report such standardized 

data under this section. 

‘‘(m) NON-APPLICATION OF PAPERWORK REDUCTION ACT.— Chapter 35 of title 44, United States Code (commonly referred 

to as the ‘Paperwork Reduction Act of 1995’) shall not apply to 
H. R. 4994—10 

this section and the sections referenced in subsection (a)(2)(B) that 

require modification in order to achieve the standardization of 

patient assessment data.’’. 

(b) STUDIES OF ALTERNATIVE PAC PAYMENT MODELS.— 

(1) MEDPAC.—Using data from the Post-Acute Payment 

Reform Demonstration authorized under section 5008 of the 

Deficit Reduction Act of 2005 (Public Law 109–171) or other 

data, as available, not later than June 30, 2016, the Medicare 

Payment Advisory Commission shall submit to Congress a 

report that evaluates and recommends features of PAC payment 

systems (as defined in section 1899B(a)(2)(D) of the Social 

Security Act, as added by subsection (a)) that establish, or 

a unified post-acute care payment system under title XVIII 

of the Social Security Act that establishes, payment rates 

according to characteristics of individuals (such as cognitive 

ability, functional status, and impairments) instead of according 

to the post-acute care setting where the Medicare beneficiary 

involved is treated. To the extent feasible, such report shall 

consider the impacts of moving from PAC payment systems 

(as defined in subsection (a)(2)(D) of such section 1899B) in 

existence as of the date of the enactment of this Act to new 

post-acute care payment systems under title XVIII of the Social 

Security Act. 

(2) RECOMMENDATIONS FOR PAC PROSPECTIVE PAYMENT.— 

(A) REPORT BY SECRETARY.—Not later than 2 years 

after the date by which the Secretary of Health and Human 

Services has collected 2 years of data on quality measures 

under subsection (c) of section 1899B, as added by subsection (a), the Secretary shall, in consultation with the 

Medicare Payment Advisory Commission and appropriate 

stakeholders, submit to Congress a report, including— 

(i) recommendations and a technical prototype, on 

a post-acute care prospective payment system under 

title XVIII of the Social Security Act that would— 

(I) in lieu of the rates that would otherwise 

apply under PAC payment systems (as defined 

in subsection (a)(2)(D) of such section 1899B), base 

payments under such title, with respect to items 

and services furnished to an individual by a PAC 

provider (as defined in subsection (a)(2)(A) of such 

section), according to individual characteristics 

(such as cognitive ability, functional status, and 

impairments) of such individual instead of the 

post-acute care setting in which the individual is 

furnished such items and services; 

(II) account for the clinical appropriateness 

of items and services so furnished and Medicare 

beneficiary outcomes; 

(III) be designed to incorporate (or otherwise 

account for) standardized patient assessment data 

under section 1899B; and 

(IV) further clinical integration, such as by 

motivating greater coordination around a single 

condition or procedure to integrate hospital systems with PAC providers (as so defined). 
H. R. 4994—11 

(ii) recommendations on which Medicare fee-forservice regulations for post-acute care payment systems under title XVIII of the Social Security Act should 

be altered (such as the skilled nursing facility 3-day 

stay and inpatient rehabilitation facility 60 percent 

rule); 

(iii) an analysis of the impact of the recommended 

payment system described in clause (i) on Medicare 

beneficiary cost-sharing, access to care, and choice of 

setting; 

(iv) a projection of any potential reduction in 

expenditures under title XVIII of the Social Security 

Act that may be attributable to the application of the 

recommended payment system described in clause (i); 

and 

(v) a review of the value of subsection (d) hospitals 

(as defined in section 1886(d)(1)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(1)(B)), hospitals 

described in section 1886(d)(1)(B)(v) of such Act (42 

U.S.C. 1395ww(d)(1)(B)(v)), and critical access hospitals described in section 1820(c)(2)(B) of such Act 

(42 U.S.C. 1395i–4(c)(2)(B)) collecting and reporting 

to the Secretary standardized patient assessment data 

with respect to inpatient hospital services furnished 

by such a hospital or critical access hospital to individuals who are entitled to benefits under part A of title 

XVIII of such Act or, as appropriate, enrolled for benefits under part B of such title. 

(B) REPORT BY MEDPAC.—Not later than the first June 

30th following the date on which the report is required 

under subparagraph (A), the Medicare Payment Advisory 

Commission shall submit to Congress a report, including 

recommendations and a technical prototype, on a postacute care prospective payment system under title XVIII 

of the Social Security Act that would satisfy the criteria 

described in subparagraph (A). 

(3) MEDICARE BENEFICIARY DEFINED.—For purposes of this 

subsection, the term ‘‘Medicare beneficiary’’ has the meaning 

given such term in section 1899B(a)(2) of the Social Security 

Act, as added by subsection (a). 

(c) PAYMENT CONSEQUENCES UNDER THE APPLICABLE

REPORTING PROVISIONS.— 

(1) HOME HEALTH AGENCIES.—Section 1895(b)(3)(B)(v) of 

the Social Security Act (42 U.S.C. 1395fff(b)(3)(B)(v)) is 

amended— 

(A) in subclause (I), by striking ‘‘subclause (II)’’ and 

inserting ‘‘subclauses (II) and (IV)’’; 

(B) in subclause (II), by striking ‘‘For 2007’’ and 

inserting ‘‘Subject to subclause (V), for 2007’’; 

(C) in subclause (III), by inserting ‘‘and subclause 

(IV)(aa)’’ after ‘‘subclause (II)’’; and 

(D) by adding at the end the following new subclauses: 

‘‘(IV) SUBMISSION OF ADDITIONAL DATA.— 

‘‘(aa) IN GENERAL.—For the year beginning 

on the specified application date (as defined 

in subsection (a)(2)(E) of section 1899B), as 
H. R. 4994—12 

applicable with respect to home health agencies and quality measures under subsection 

(c)(1) of such section and measures under subsection (d)(1) of such section, and each subsequent year, in addition to the data described 

in subclause (II), each home health agency 

shall submit to the Secretary data on such 

quality measures and any necessary data 

specified by the Secretary under such subsection (d)(1). 

‘‘(bb) STANDARDIZED PATIENT ASSESSMENT

DATA.—For 2019 and each subsequent year, 

in addition to such data described in item 

(aa), each home health agency shall submit 

to the Secretary standardized patient assessment data required under subsection (b)(1) of 

section 1899B. 

‘‘(cc) SUBMISSION.—Data shall be submitted under items (aa) and (bb) in the form 

and manner, and at the time, specified by 

the Secretary for purposes of this clause. 

‘‘(V) NON-DUPLICATION.—To the extent data 

submitted under subclause (IV) duplicates other 

data required to be submitted under subclause 

(II), the submission of such data under subclause 

(IV) shall be in lieu of the submission of such 

data under subclause (II). The previous sentence 

shall not apply insofar as the Secretary determines 

it is necessary to avoid a delay in the implementation of section 1899B, taking into account the different specified application dates under subsection 

(a)(2)(E) of such section.’’. 

(2) INPATIENT REHABILITATION FACILITIES.—Section 

1886(j)(7) of the Social Security Act (42 U.S.C. 1395ww(j)(7)) 

is amended— 

(A) in subparagraph (A)(i), by striking ‘‘subparagraph 

(C)’’ and inserting ‘‘subparagraphs (C) and (F)’’; 

(B) in subparagraph (C), by striking ‘‘For fiscal year 

2014 and each subsequent rate year’’ and inserting ‘‘Subject 

to subparagraph (G), for fiscal year 2014 and each subsequent fiscal year’’; 

(C) in subparagraph (E), by inserting ‘‘and subparagraph (F)(i)’’ after ‘‘subparagraph (C)’’; and 

(D) by adding at the end the following new subparagraphs: 

‘‘(F) SUBMISSION OF ADDITIONAL DATA.— 

‘‘(i) IN GENERAL.—For the fiscal year beginning 

on the specified application date (as defined in subsection (a)(2)(E) of section 1899B), as applicable with 

respect to inpatient rehabilitation facilities and quality 

measures under subsection (c)(1) of such section and 

measures under subsection (d)(1) of such section, and 

each subsequent fiscal year, in addition to such data 

on the quality measures described in subparagraph 

(C), each rehabilitation facility shall submit to the 

Secretary data on the quality measures under such 
H. R. 4994—13 

subsection (c)(1) and any necessary data specified by 

the Secretary under such subsection (d)(1). 

‘‘(ii) STANDARDIZED PATIENT ASSESSMENT DATA.— 

For fiscal year 2019 and each subsequent fiscal year, 

in addition to such data described in clause (i), each 

rehabilitation facility shall submit to the Secretary 

standardized patient assessment data required under 

subsection (b)(1) of section 1899B. 

‘‘(iii) SUBMISSION.—Such data shall be submitted 

in the form and manner, and at the time, specified 

by the Secretary for purposes of this subparagraph. 

‘‘(G) NON-DUPLICATION.—To the extent data submitted 

under subparagraph (F) duplicates other data required to 

be submitted under subparagraph (C), the submission of 

such data under subparagraph (F) shall be in lieu of the 

submission of such data under subparagraph (C). The previous sentence shall not apply insofar as the Secretary 

determines it is necessary to avoid a delay in the 

implementation of section 1899B, taking into account the 

different specified application dates under subsection 

(a)(2)(E) of such section.’’. 

(3) LONG-TERM CARE HOSPITALS.—Section 1886(m)(5) of the 

Social Security Act (42 U.S.C. 1395ww(m)(5)) is amended— 

(A) in subparagraph (A)(i), by striking ‘‘subparagraph 

(C)’’ and inserting ‘‘subparagraphs (C) and (F)’’; 

(B) in subparagraph (C), by striking ‘‘For rate year’’ 

and inserting ‘‘Subject to subparagraph (G), for rate year’’; 

(C) in subparagraph (E), by inserting ‘‘and subparagraph (F)(i)’’ after ‘‘subparagraph (C)’’; and 

(D) by adding at the end the following new subparagraphs: 

‘‘(F) SUBMISSION OF ADDITIONAL DATA.— 

‘‘(i) IN GENERAL.—For the rate year beginning on 

the specified application date (as defined in subsection 

(a)(2)(E) of section 1899B), as applicable with respect 

to long-term care hospitals and quality measures under 

subsection (c)(1) of such section and measures under 

subsection (d)(1) of such section, and each subsequent 

rate year, in addition to the data on the quality measures described in subparagraph (C), each long-term 

care hospital (other than a hospital classified under 

subsection (d)(1)(B)(iv)(II)) shall submit to the Secretary data on the quality measures under such subsection (c)(1) and any necessary data specified by the 

Secretary under such subsection (d)(1). 

‘‘(ii) STANDARDIZED PATIENT ASSESSMENT DATA.— For rate year 2019 and each subsequent rate year, 

in addition to such data described in clause (i), each 

long-term care hospital (other than a hospital classified 

under subsection (d)(1)(B)(iv)(II)) shall submit to the 

Secretary standardized patient assessment data 

required under subsection (b)(1) of section 1899B. 

‘‘(iii) SUBMISSION.—Such data shall be submitted 

in the form and manner, and at the time, specified 

by the Secretary for purposes of this subparagraph. 

‘‘(G) NON-DUPLICATION.—To the extent data submitted 

under subparagraph (F) duplicates other data required to 
H. R. 4994—14 

be submitted under subparagraph (C), the submission of 

such data under subparagraph (F) shall be in lieu of the 

submission of such data under subparagraph (C). The previous sentence shall not apply insofar as the Secretary 

determines it is necessary to avoid a delay in the 

implementation of section 1899B, taking into account the 

different specified application dates under subsection 

(a)(2)(E) of such section.’’. 

(4) SKILLED NURSING FACILITIES.— 

(A) IN GENERAL.—Paragraph (6) of section 1888(e) of 

the Social Security Act (42 U.S.C. 1395yy(e)) is amended 

to read as follows: 

‘‘(6) REPORTING OF ASSESSMENT AND QUALITY DATA.— 

‘‘(A) REDUCTION IN UPDATE FOR FAILURE TO REPORT.— 

‘‘(i) IN GENERAL.—For fiscal years beginning with 

fiscal year 2018, in the case of a skilled nursing facility 

that does not submit data, as applicable, in accordance 

with subclauses (II) and (III) of subparagraph (B)(i) 

with respect to such a fiscal year, after determining 

the percentage described in paragraph (5)(B)(i), and 

after application of paragraph (5)(B)(ii), the Secretary 

shall reduce such percentage for payment rates during 

such fiscal year by 2 percentage points. 

‘‘(ii) SPECIAL RULE.—The application of this 

subparagraph may result in the percentage described 

in paragraph (5)(B)(i), after application of paragraph 

(5)(B)(ii), being less than 0.0 for a fiscal year, and 

may result in payment rates under this subsection 

for a fiscal year being less than such payment rates 

for the preceding fiscal year. 

‘‘(iii) NONCUMULATIVE APPLICATION.—Any reduction under clause (i) shall apply only with respect 

to the fiscal year involved and the Secretary shall 

not take into account such reduction in computing 

the payment amount under this subsection for a subsequent fiscal year. 

‘‘(B) ASSESSMENT AND MEASURE DATA.— 

‘‘(i) IN GENERAL.—A skilled nursing facility, or a 

facility (other than a critical access hospital) described 

in paragraph (7)(B), shall submit to the Secretary, 

in a manner and within the timeframes prescribed 

by the Secretary— 

‘‘(I) subject to clause (iii), the resident assessment data necessary to develop and implement 

the rates under this subsection; 

‘‘(II) for fiscal years beginning on or after the 

specified application date (as defined in subsection 

(a)(2)(E) of section 1899B), as applicable with 

respect to skilled nursing facilities and quality 

measures under subsection (c)(1) of such section 

and measures under subsection (d)(1) of such section, data on such quality measures under such 

subsection (c)(1) and any necessary data specified 

by the Secretary under such subsection (d)(1); and 

‘‘(III) for fiscal years beginning on or after 

October 1, 2018, standardized patient assessment 
H. R. 4994—15 

data required under subsection (b)(1) of section 

1899B. 

‘‘(ii) USE OF STANDARD INSTRUMENT.—For purposes 

of meeting the requirement under clause (i), a skilled 

nursing facility, or a facility (other than a critical 

access hospital) described in paragraph (7)(B), may 

submit the resident assessment data required under 

section 1819(b)(3), using the standard instrument designated by the State under section 1819(e)(5). 

‘‘(iii) NON-DUPLICATION.—To the extent data submitted under subclause (II) or (III) of clause (i) duplicates other data required to be submitted under clause 

(i)(I), the submission of such data under such a subclause shall be in lieu of the submission of such data 

under clause (i)(I). The previous sentence shall not 

apply insofar as the Secretary determines it is necessary to avoid a delay in the implementation of section 

1899B, taking into account the different specified 

application dates under subsection (a)(2)(E) of such 

section.’’. 

(B) FUNDING FOR NURSING HOME COMPARE WEBSITE.— 

Section 1819(i) of the Social Security Act (42 U.S.C. 1395i– 

3(i)) is amended by adding at the end the following new 

paragraph: 

‘‘(3) FUNDING.—The Secretary shall transfer to the Centers 

for Medicare & Medicaid Services Program Management 

Account, from the Federal Hospital Insurance Trust Fund under 

section 1817 a one-time allocation of $11,000,000. The amount 

shall be available on the date of the enactment of this paragraph. Such sums shall remain available until expended. Such 

sums shall be used to implement section 1128I(g).’’. 

(d) IMPROVING PAYMENT ACCURACY UNDER THE PAC PAYMENT

SYSTEMS AND OTHER MEDICARE PAYMENT SYSTEMS.— 

(1) STUDIES AND REPORTS OF EFFECT OF CERTAIN INFORMATION ON QUALITY AND RESOURCE USE.— 

(A) STUDY USING EXISTING MEDICARE DATA.— 

(i) STUDY.—The Secretary of Health and Human 

Services (in this subsection referred to as the ‘‘Secretary’’) shall conduct a study that examines the effect 

of individuals’ socioeconomic status on quality measures and resource use and other measures for individuals under the Medicare program under title XVIII 

of the Social Security Act (42 U.S.C. 1395 et seq.) 

(such as to recognize that less healthy individuals may 

require more intensive interventions). The study shall 

use information collected on such individuals in carrying out such program, such as urban and rural location, eligibility for Medicaid under title XIX of such 

Act (42 U.S.C. 1396 et seq.) (recognizing and 

accounting for varying Medicaid eligibility across 

States), and eligibility for benefits under the supplemental security income (SSI) program. The Secretary 

shall carry out this paragraph acting through the 

Assistant Secretary for Planning and Evaluation. 

(ii) REPORT.—Not later than 2 years after the date 

of the enactment of this Act, the Secretary shall submit 
H. R. 4994—16 

to Congress a report on the study conducted under 

clause (i). 

(B) STUDY USING OTHER DATA.— 

(i) STUDY.—The Secretary shall conduct a study 

that examines the impact of risk factors, such as those 

described in section 1848(p)(3) of the Social Security 

Act (42 U.S.C. 1395w–4(p)(3)), race, health literacy, 

limited English proficiency (LEP), and Medicare beneficiary activation, on quality measures and resource 

use and other measures under the Medicare program 

(such as to recognize that less healthy individuals may 

require more intensive interventions). In conducting 

such study the Secretary may use existing Federal 

data and collect such additional data as may be necessary to complete the study. 

(ii) REPORT.—Not later than 5 years after the date 

of the enactment of this Act, the Secretary shall submit 

to Congress a report on the study conducted under 

clause (i). 

(C) EXAMINATION OF DATA IN CONDUCTING STUDIES.— 

In conducting the studies under subparagraphs (A) and 

(B), the Secretary shall examine what non-Medicare data 

sets, such as data from the American Community Survey 

(ACS), can be useful in conducting the types of studies 

under such paragraphs and how such data sets that are 

identified as useful can be coordinated with Medicare 

administrative data in order to improve the overall data 

set available to do such studies and for the administration 

of the Medicare program. 

(D) RECOMMENDATIONS TO ACCOUNT FOR INFORMATION

IN PAYMENT ADJUSTMENT MECHANISMS.—If the studies conducted under subparagraphs (A) and (B) find a relationship 

between the factors examined in the studies and quality 

measures and resource use and other measures, then the 

Secretary shall also provide recommendations for how the 

Centers for Medicare & Medicaid Services should— 

(i) obtain access to the necessary data (if such 

data is not already being collected) on such factors, 

including recommendations on how to address barriers 

to the Centers in accessing such data; and 

(ii) account for such factors— 

(I) in quality measures, resource use measures, and other measures under title XVIII of the 

Social Security Act (including such measures specified under subsections (c) and (d) of section 1899B 

of such Act, as added by subsection (a)); and 

(II) in determining payment adjustments 

based on such measures in other applicable provisions of such title. 

(E) FUNDING.—There are hereby appropriated to the 

Secretary from the Federal Hospital Insurance Trust Fund 

under section 1817 of the Social Security Act (42 U.S.C. 

1395i) and the Federal Supplementary Medical Insurance 

Trust Fund under section 1841 of such Act (42 U.S.C. 

1395t) (in proportions determined appropriate by the Secretary) to carry out this paragraph $6,000,000, to remain 

available until expended. 
H. R. 4994—17 

(2) CMS ACTIVITIES.— 

(A) IN GENERAL.—Taking into account the relevant 

studies conducted and recommendations made in reports 

under paragraph (1) and, as appropriate, other information, 

including information collected before completion of such 

studies and recommendations, the Secretary, on an ongoing 

basis, shall, as the Secretary determines appropriate and 

based on an individual’s health status and other factors— 

(i) assess appropriate adjustments to quality measures, resource use measures, and other measures under 

title XVIII of the Social Security Act (42 U.S.C. 1395 

et seq.) (including measures specified in subsections 

(c) and (d) of section 1899B of such Act, as added 

by subsection (a)); and 

(ii) assess and implement appropriate adjustments 

to payments under such title based on measures 

described in clause (i). 

(B) ACCESSING DATA.—The Secretary shall collect or 

otherwise obtain access to the data necessary to carry 

out this paragraph through existing and new data sources. 

(C) PERIODIC ANALYSES.—The Secretary shall carry out 

periodic analyses, at least every 3 years, based on the 

factors referred to in subparagraph (A) so as to monitor 

changes in possible relationships. 

(D) FUNDING.—There are hereby appropriated to the 

Secretary from the Federal Hospital Insurance Trust Fund 

under section 1817 of the Social Security Act (42 U.S.C. 

1395i) and the Federal Supplementary Medical Insurance 

Trust Fund under section 1841 of such Act (42 U.S.C. 

1395t) (in proportions determined appropriate by the Secretary) to carry out this paragraph $10,000,000, to remain 

available until expended. 

(3) STRATEGIC PLAN FOR ACCESSING RACE AND ETHNICITY

DATA.—Not later than 18 months after the date of the enactment of this Act, the Secretary shall develop and report to 

Congress on a strategic plan for collecting or otherwise 

accessing data on race and ethnicity for purposes of specifying 

quality measures and resource use and other measures under 

subsections (c) and (d) of section 1899B of the Social Security 

Act, as added by subsection (a), and, as the Secretary determines appropriate, other similar provisions of, including payment adjustments under, title XVIII of such Act (42 U.S.C. 

1395 et seq.). 

SEC. 3. HOSPICE CARE. 

(a) HOSPICE SURVEY REQUIREMENT.— (1) IN GENERAL.—Section 1861(dd)(4) of the Social Security 

Act (42 U.S.C. 1395x(dd)(4)) is amended by adding at the end 

the following new subparagraph: 

‘‘(C) Any entity that is certified as a hospice program shall 

be subject to a standard survey by an appropriate State or local 

survey agency, or an approved accreditation agency, as determined 

by the Secretary, not less frequently than once every 36 months 

beginning 6 months after the date of the enactment of this subparagraph and ending September 30, 2025.’’. 

(2) FUNDING.—For purposes of carrying out subparagraph 

(C) of section 1861(dd)(4) of the Social Security Act (42 U.S.C. 
H. R. 4994—18 

1395x(dd)(4)), as added by paragraph (1), there shall be transferred from the Federal Hospital Insurance Trust Fund under 

section 1817 of such Act (42 U.S.C. 1395i) to the Centers 

for Medicare & Medicaid Services Program Management 

Account— 

(A) $25,000,000 for fiscal years 2015 through 2017, 

to be made available for such purposes in equal parts 

for each such fiscal year; and 

(B) $45,000,000 for fiscal years 2018 through 2025, 

to be made available for such purposes in equal parts 

for each such fiscal year. 

(b) HOSPICE PROGRAM ELIGIBILITY RECERTIFICATION TECHNICAL

CORRECTION TO APPLY LIMITATION ON LIABILITY OF BENEFICIARY

RULES.—Section 1879 of the Social Security Act (42 U.S.C. 1395pp) 

is amended by adding at the end the following new subsection: 

‘‘(i) The provisions of this section shall apply with respect 

to a denial of a payment under this title by reason of section 

1814(a)(7)(E) in the same manner as such provisions apply with 

respect to a denial of a payment under this title by reason of 

section 1862(a)(1).’’. 

(c) REVISION TO REQUIREMENT FOR MEDICAL REVIEW OF CERTAIN HOSPICE CARE.—Section 1814(a)(7) of the Social Security Act 

(42 U.S.C. 1395f(a)(7)) is amended— 

(1) in subparagraph (C), by striking ‘‘and’’ at the end; 

(2) in subparagraph (D), in the matter preceding clause 

(i), by inserting ‘‘(and, in the case of clause (ii), before the 

date of enactment of subparagraph (E))’’ after ‘‘2011’’; and 

(3) by adding at the end the following new subparagraph: 

‘‘(E) on and after the date of enactment of this subparagraph, in the case of hospice care provided an individual 

for more than 180 days by a hospice program for which 

the number of such cases for such program comprises more 

than a percent (specified by the Secretary) of the total 

number of all cases of individuals provided hospice care 

by the program under this title, the hospice care provided 

to such individual is medically reviewed (in accordance 

with procedures established by the Secretary); and’’. 

(d) UPDATE OF HOSPICE AGGREGATE PAYMENT CAP.—Section 

1814(i)(2)(B) of the Social Security Act (42 U.S.C. 1395f(i)(2)(B)) 

is amended— 

(1) by striking ‘‘(B) For purposes’’ and inserting ‘‘(B)(i) 

Except as provided in clause (ii), for purposes’’; and 

(2) by adding at the end the following: 

‘‘(ii) For purposes of subparagraph (A) for accounting years 

that end after September 30, 2016, and before October 1, 2025, 

the ‘cap amount’ is the cap amount under this subparagraph for 

the preceding accounting year updated by the percentage update 

to payment rates for hospice care under paragraph (1)(C) for services furnished during the fiscal year beginning on the October 

1 preceding the beginning of the accounting year (including the 

application of any productivity or other adjustment under clause 

(iv) of that paragraph). 

‘‘(iii) For accounting years that end after September 30, 2025, 

the cap amount shall be computed under clause (i) as if clause 

(ii) had never applied.’’. 

(e) MEDICARE IMPROVEMENT FUND.—Section 1898 of the Social 

Security Act (42 U.S.C. 1395iii) is amended— 
H. R. 4994—19 

(1) by amending the heading to read as follows: ‘‘MEDICARE

IMPROVEMENT FUND’’; 

(2) by amending subsection (a) to read as follows: 

‘‘(a) ESTABLISHMENT.—The Secretary shall establish under this 

title a Medicare Improvement Fund (in this section referred to 

as the ‘Fund’) which shall be available to the Secretary to make 

improvements under the original Medicare fee-for-service program 

under parts A and B for individuals entitled to, or enrolled for, 

benefits under part or enrolled under part B including adjustments 

to payments for items and services furnished by providers of services 

and suppliers under such original Medicare fee-for-service program.’’; 

(3) in subsection (b)(1), by striking ‘‘during’’ and all that 

follows and inserting ‘‘during and after fiscal year 2020, 

$195,000,000.’’; and 

(4) in subsection (b)(2), by striking ‘‘from the Federal’’ and 

all that follows and inserting ‘‘from the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund in such proportion as the Secretary determines 

appropriate.’’. 

Speaker of the House of Representatives. 

Vice President of the United States and

President of the Senate.