Improving Access to Medicare Coverage Act of 2015

To amend title XVIII of the Social Security Act to count a period of receipt of outpatient observation services in a hospital toward satisfying the 3-day inpatient hospital stay requirement for coverage of skilled nursing facility services under Medicare, and for other purposes. 1. Short title This Act may be cited as the Improving Access to Medicare Coverage Act of 2015 2. Findings Congress finds the following: (1) Medicare requires beneficiaries to be hospitalized for medically necessary inpatient hospital care for at least three consecutive days before covering post-hospital care in a skilled nursing facility under section 1861(i) of the Social Security Act ( 42 U.S.C. 1395x(i) (2) Often patients remain under observation status (3) Hospitals’ use of observation stays has increased sharply since 2006. According to the March 2014 report of the Medicare Payment Advisory Commission, outpatient visits, many of which are observation stays, increased 28.5 percent between 2006 and 2012, with a simultaneous 12.6 percent decrease in inpatient stays over this same six-year time period. A study published in Health Affairs found a 34-percent increase in the ratio of observation stays to inpatient admissions between 2007 and 2009, leading the researchers to conclude that outpatient observation status was becoming a substitute for inpatient admission. The same study also documented increases in long-stay outpatient status, including an 88-percent increase in observation stays exceeding 72 hours. (4) To health care providers, care provided during observation is indistinguishable from the care provided to inpatients and all medically necessary care is provided, regardless of patient status. Beneficiaries are generally not informed of their inpatient or outpatient status and assume that they are inpatients when they are placed in a hospital bed, only to find out that such care was not counted for purposes of satisfying eligibility requirements for medically prescribed Medicare coverage of post-hospital care in a skilled nursing facility. (5) Older Americans and people with disabilities who are hospitalized but do not meet the 3-day inpatient hospital stay requirement simply because they were placed in outpatient observation status (6) The Centers for Medicare & Medicaid Services (CMS) attempted to provide hospitals with clarity on which patients should be categorized as inpatients in the inpatient hospital payment rule for fiscal year 2014. However, this rule fails Medicare beneficiaries because it does not address the problem and explicitly states that days spent in observation status do not count for purposes of satisfying the 3-day inpatient stay requirement. (7) Because of CMS’ policy which indicates days under observation do not count towards the 3-day inpatient stay requirement, some patients under observation and their families will continue to face a significant, often insurmountable financial burden if they need skilled nursing care after their hospital stay. (8) This Act updates Medicare policy by deeming patients under observation as inpatients for the purposes of satisfying the Medicare 3-day inpatient stay requirement. This Act does not repeal the 3-day inpatient stay requirement; rather it simply expands the Secretary’s administrative definition of inpatient (9) It is the intent of this Congress, through this Act, to allow access to skilled nursing care for the population of beneficiaries who meet medical necessity requirements for such care, but who do not satisfy the 3-day inpatient stay requirement simply because some or all of their time in the acute care hospital is characterized as outpatient observation status (10) It is the understanding of Congress that the Secretary of Health and Human Services will monitor patterns of behavior to ensure that providers deliver appropriate and needed levels of care. (11) The Office of the Inspector General of the Department of Health and Human Services is supportive of counting hospital observation days towards the 3-day inpatient stay requirement. In addition, in September 2013, the Congressionally established Commission on Long-Term Care recommended that CMS count time spent in observation status toward meeting Medicare’s 3-day stay requirement. 3. Counting a period of receipt of outpatient observation services in a hospital toward the 3-day inpatient hospital stay requirement for coverage of skilled nursing facility services under medicare (a) In general Section 1861(i) of the Social Security Act ( 42 U.S.C. 1395x(i) For purposes of this subsection, an individual receiving outpatient observation services shall be deemed to be an inpatient during such period, and the date such individual ceases receiving such services shall be deemed the hospital discharge date (unless such individual is admitted as a hospital inpatient at the end of such period). (b) Effective date The amendment made by subsection (a) shall apply to receipt of outpatient observation services beginning on or after January 1, 2015, but applies to a period of post-hospital extended care services that was completed before the date of the enactment of this Act only if an administrative appeal is or has been made with respect to such services not later than 90 days after the date of the enactment of this Act. Notwithstanding any other provision of law, the Secretary of Health and Human Services may implement such amendment through an interim final regulation, program instruction, or otherwise.

Summary: Improving Access to Medicare Coverage Act of 2015 Amends title XVIII (Medicare) of the Social Security Act to deem an individual receiving outpatient observation services in a hospital to be an inpatient with respect to satisfying the three-day inpatient hospital requirement in order to entitle the individual to Medicare coverage of any post-hospital extended care services in a skilled nursing facility.