I

104TH CONGRESS

2D SESSION H. R. 4244

To require the Secretary of Health and Human Services to waive the 3-

day prior hospitalization requirement for coverage of skilled nursing

facility services in the case of individuals classified within certain diagnosis-related groups.

IN THE HOUSE OF REPRESENTATIVES

SEPTEMBER 27, 1996

Mr. DURBIN (for himself and Mr. ENSIGN) introduced the following bill; which

was referred to the Committee on Ways and Means

A BILL

To require the Secretary of Health and Human Services

to waive the 3-day prior hospitalization requirement for

coverage of skilled nursing facility services in the case

of individuals classified within certain diagnosis-related

groups.

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. WAIVER OF 3-DAY PRIOR HOSPITALIZATION RE2 QUIREMENT FOR COVERAGE OF SKILLED

3 NURSING FACILITY SERVICES FOR CERTAIN

4 DRGS.

5 (a) IN GENERAL.—By not later than October 1,

6 1997, the Secretary of Health and Human Services shall

7 provide for coverage, under section 1812(f) of the Social

8 Security Act, of extended care services for individuals with

9 a condition that is classifiable within a diagnosis-related

10 group selected under subsection (b).

11 (b) SELECTION OF DIAGNOSIS-RELATED GROUPS.—

12 For purposes of subsection (a) and subject to subsections

13 (c) and (d), the Secretary—

14 (1) beginning with fiscal year 1998, shall select

15 at least 5 diagnosis-related groups (as established

16 for purposes of section 1886(d)(4)(A) of the Social

17 Security Act) that—

18 (A) relate to conditions that do not require

19 treatment through receipt of inpatient hospital

20 services, and

21 (B) are not likely (or are least likely) to re22 sult in any net increased expenditures under

23 title XVIII of such Act; and

24 (2) for subsequent fiscal years may select addi25 tional diagnosis-related groups that meet the re-
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1 quirements of subparagraphs (A) and (B) of para2 graph (1).

3 (c) RECOVERY OF EXCESS EXPENDITURES.—If the

4 Secretary determines that the application of this section

5 in a fiscal year has resulted in any increase in aggregate

6 expenditures under such title for the fiscal year above the

7 amount of such expenditures that would have occurred in

8 the fiscal year if this section did not apply (taking into

9 account any reductions in expenditures resulting from the

10 elimination of or a reduction in the length of hospitaliza11 tion), the Secretary—

12 (1) shall, notwithstanding any other provision

13 of law, provide for a reduction in the amounts other14 wise payable under part A of such title for post-hos15 pital extended care services in the following fiscal

16 year by such proportion as will reduce aggregate

17 Federal expenditures in such fiscal year under such

18 part by the aggregate amount of such an increase in

19 the previous fiscal year, and

20 (2) may rescind the selection of any diagnosis21 related group if the application of this section with

22 respect to such group has resulted in such an in23 crease in expenditures under such title.

24 (d) CONSIDERATION OF ADDITIONAL SELECTIONS.—

25 The Secretary shall actively consider the selection of addi-
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1 tional groups under subsection (b)(2) if the Secretary de2 termines that the application of this section has resulted

3 in a net reduction in expenditures under such title.

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