II 
113TH CONGRESS 
2D SESSION 
H. R. 4994 
IN THE SENATE OF THE UNITED STATES 
SEPTEMBER 17 (legislative day, SEPTEMBER 16), 2014 
Received 
AN ACT 
To amend title XVIII of the Social Security Act to provide 
for standardized post-acute care assessment data for 
quality, payment, and discharge planning, and for other 
purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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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) AS-
SESSMENT DATA FOR QUALITY, PAYMENT, 
AND DISCHARGE PLANNING. 
‘‘(a) REQUIREMENT
FOR STANDARDIZED ASSESS-
MENT 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 subpara-
graph (A) to be standardized and interoperable 
so as to allow for the exchange of such data 
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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 informa-
tion for such providers to facilitate coordinated 
care and improved Medicare beneficiary out-
comes; 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 pro-
viders; and 
‘‘(ii) enable comparison of such as-
sessment data across all such providers to 
whom such data are applicable. 
‘‘(2) DEFINITIONS.—For purposes of this sec-
tion: 
‘‘(A) 
POST-ACUTE
CARE
(PAC)
PRO-
VIDER.—The terms ‘post-acute care provider’ 
and ‘PAC provider’ mean— 
‘‘(i) a home health agency; 
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‘‘(ii) a skilled nursing facility; 
‘‘(iii) an inpatient rehabilitation facil-
ity; 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 agen-
cies, 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 fa-
cilities, the resident’s assessment under 
section 1819(b)(3); 
‘‘(iii) in the case of inpatient rehabili-
tation facilities, any Medicare beneficiary 
assessment instrument established by the 
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Secretary for purposes of section 1886(j); 
and 
‘‘(iv) in the case of long-term care 
hospitals, the Medicare beneficiary assess-
ment 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), in-
cluding 
for 
purposes 
of 
section 
1886(m)(5)(C), or any other instrument 
used with respect to such hospitals for as-
sessment purposes. 
‘‘(C) 
APPLICABLE
REPORTING
PROVI-
SION.—The term ‘applicable reporting provi-
sion’ means— 
‘‘(i) for home health agencies, section 
1895(b)(3)(B)(v); 
‘‘(ii) for skilled nursing facilities, sec-
tion 1888(e)(6); 
‘‘(iii) for inpatient rehabilitation facili-
ties, section 1886(j)(7); and 
‘‘(iv) for long-term care hospitals, sec-
tion 1886(m)(5). 
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‘‘(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 re-
habilitation facility, the prospective pay-
ment 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 fol-
lowing: 
‘‘(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) (re-
lating to functional status, cognitive 
function, and changes in function and 
cognitive function)— 
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‘‘(aa) for PAC providers de-
scribed in clauses (ii) and (iii) of 
paragraph (2)(A), October 1, 
2016; 
‘‘(bb) for PAC providers de-
scribed in clause (iv) of such 
paragraph, October 1, 2018; and 
‘‘(cc) for PAC providers de-
scribed in clause (i) of such para-
graph, January 1, 2019; 
‘‘(II) with respect to the domain 
described in subsection (c)(1)(B) (re-
lating to skin integrity and changes in 
skin integrity)— 
‘‘(aa) for PAC providers de-
scribed in clauses (ii), (iii), and 
(iv) of paragraph (2)(A), October 
1, 2016; and 
‘‘(bb) for PAC providers de-
scribed in clause (i) of such para-
graph, January 1, 2017; 
‘‘(III) with respect to the domain 
described in subsection (c)(1)(C) (re-
lating to medication reconciliation)— 
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‘‘(aa) for PAC providers de-
scribed in clause (i) of such para-
graph, January 1, 2017; and 
‘‘(bb) for PAC providers de-
scribed in clauses (ii), (iii), and 
(iv) of such paragraph, October 
1, 2018; 
‘‘(IV) with respect to the domain 
described in subsection (c)(1)(D) (re-
lating to incidence of major falls)— 
‘‘(aa) for PAC providers de-
scribed in clauses (ii), (iii), and 
(iv) of paragraph (2)(A), October 
1, 2016; and 
‘‘(bb) for PAC providers de-
scribed in clause (i) of such para-
graph, January 1, 2019; and 
‘‘(V) with respect to the domain 
described in subsection (c)(1)(E) (re-
lating to accurately communicating 
the existence of and providing for the 
transfer of health information and 
care preferences)— 
‘‘(aa) for PAC providers de-
scribed in clauses (ii), (iii), and 
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(iv) of paragraph (2)(A), October 
1, 2018; and 
‘‘(bb) for PAC providers de-
scribed in clause (i) of such para-
graph, 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 para-
graph (2)(A), October 1, 2016; and 
‘‘(II) for PAC providers de-
scribed in clause (i) of such para-
graph, January 1, 2017. 
‘‘(F) MEDICARE BENEFICIARY.—The term 
‘Medicare beneficiary’ means an individual enti-
tled to benefits under part A or, as appropriate, 
enrolled for benefits under part B. 
‘‘(b) STANDARDIZED PATIENT ASSESSMENT DATA.— 
‘‘(1) REQUIREMENT FOR REPORTING ASSESS-
MENT DATA.— 
‘‘(A) IN
GENERAL.—Beginning not later 
than October 1, 2018, for PAC providers de-
scribed in clauses (ii), (iii), and (iv) of sub-
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section (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 stand-
ardized patient assessment data described in 
subparagraph (B). The Secretary shall require 
such data be submitted with respect to admis-
sion and discharge of an individual (and may be 
submitted more frequently as the Secretary 
deems appropriate). 
‘‘(B) STANDARDIZED
PATIENT
ASSESS-
MENT DATA DESCRIBED.—For purposes of sub-
paragraph (A), the standardized patient assess-
ment 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 mobil-
ity and self care at admission to a PAC 
provider and before discharge from a PAC 
provider. 
‘‘(ii) Cognitive function, such as abil-
ity to express ideas and to understand, and 
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mental status, such as depression and de-
mentia. 
‘‘(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 inconti-
nence and an impaired ability to hear, see, 
or swallow. 
‘‘(vi) Other categories deemed nec-
essary 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 con-
current service use, such as antecedent hospital or 
PAC provider use, and may use such matched data 
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for such other uses as the Secretary determines ap-
propriate. 
‘‘(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 para-
graph (1), the Secretary shall, as soon as prac-
ticable, revise or replace such existing data with the 
standardized data. 
‘‘(4) CLARIFICATION.—Standardized patient as-
sessment data submitted pursuant to this subsection 
shall not be used to require individuals to be pro-
vided post-acute care by a specific type of PAC pro-
vider in order for such care to be eligible for pay-
ment 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 applica-
ble reporting provisions to submit standardized pa-
tient assessment data described in subsection (b)(1) 
and other necessary data specified by the Secretary. 
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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 in-
tegrity. 
‘‘(C) Medication reconciliation. 
‘‘(D) Incidence of major falls. 
‘‘(E) Accurately communicating the exist-
ence of and providing for the transfer of health 
information and care preferences of an indi-
vidual 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, in-
cluding 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.— 
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‘‘(1) REQUIREMENT FOR RESOURCE USE AND 
OTHER MEASURES.—Not later than the specified ap-
plication date, as applicable to measures and PAC 
providers, the Secretary shall specify resource use 
and other measures on which PAC providers are re-
quired under the applicable reporting provisions to 
submit any necessary data specified by the Sec-
retary, 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 bene-
ficiary. 
‘‘(B) Discharge to community. 
‘‘(C) Measures to reflect all-condition risk- 
adjusted potentially preventable hospital read-
mission 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 appro-
priate, align resource use with the methodology 
used for purposes of section 1886(o)(2)(B)(ii). 
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‘‘(B) GEOGRAPHIC
AND
OTHER
ADJUST-
MENTS.—The Secretary shall standardize meas-
ures 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 modifica-
tions made to the methodology. 
‘‘(C) MEDICARE
SPENDING
PER
BENE-
FICIARY.—The Secretary shall adjust, as appro-
priate, measures with respect to the domain de-
scribed in paragraph (1)(A) for the factors ap-
plied 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. 
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‘‘(B) RISK ADJUSTMENT.—Such resource 
use and other measures shall be risk adjusted, 
as determined appropriate by the Secretary. 
‘‘(e) MEASUREMENT IMPLEMENTATION PHASES; SE-
LECTION 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 pro-
visions of this section shall be implemented in ac-
cordance 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 nu-
merator, denominator, exclusions, and any 
other aspects the Secretary determines 
necessary; 
‘‘(ii) data collection, including, in the 
case of quality measures, requiring PAC 
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providers to report data elements needed 
to calculate such a measure; and 
‘‘(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 ac-
cordance 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 meas-
ure in accordance with subsection (g). 
‘‘(2) CONSENSUS-BASED ENTITY.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), each measure specified by the Sec-
retary under this section shall be endorsed by 
the entity with a contract under section 
1890(a). 
‘‘(B) EXCEPTION.—In the case of a speci-
fied area or medical topic determined appro-
priate by the Secretary for which a feasible and 
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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 subpara-
graph (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 proce-
dures, such as ad-hoc reviews, as nec-
essary, in the case of a quality measure 
specified under subsection (c) or a resource 
use or other measure specified in sub-
section (d) required with respect to data 
submissions under the applicable reporting 
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provisions during the 1-year period before 
the specified application date applicable to 
such a measure and provider involved. 
‘‘(ii) 
OPTION
TO
WAIVE
PROVI-
SIONS.—The Secretary may waive the ap-
plication of the provisions of section 1890A 
in the case of a quality measure or re-
source use or other measure described in 
clause (i), if the application of such provi-
sions (including through the use of an ex-
pedited procedure described in such clause) 
would result in the inability of the Sec-
retary 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 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 
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