I 
112TH CONGRESS 
2D SESSION 
H. R. 6413 
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 
SEPTEMBER 14, 2012 
Mr. BLUMENAUER (for himself, Mr. PETRI, Ms. SCHWARTZ, and Ms. SCHA-
KOWSKY) introduced the following bill; which was referred to the Com-
mittee 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. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Medicare Transitional 
Care Act of 2012’’. 
SEC. 2. FINDINGS. 
Congress finds the following: 
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(1) More than 20 percent of older Americans 
suffer from 5 or more chronic conditions and these 
older adults typically require health care services 
from numerous providers across several care settings 
each year. 
(2) Insufficient communication among older 
adults, family caregivers, and health care providers 
during transitions from one care setting to another 
contributes to poor continuity of care, inadequate 
management of complex health care needs, medica-
tion errors, and preventable hospital readmissions. 
These failures create serious patient safety, quality 
of care, and health outcome concerns. 
(3) Research suggests that family caregivers 
often lack the knowledge, skills, and resources to ef-
fectively address the complex needs of older adults 
coping with multiple coexisting conditions. 
(4) In 2005, health care services for Medicare 
beneficiaries with 5 or more chronic conditions ac-
counted for 75 percent of total Medicare spending. 
The vast majority of these costs were due to high 
rates of hospital admission and readmission. 
(5) According to Medicare claims data from 
2003–2004, almost one fifth (19.6 percent) of the 
11,855,702 Medicare beneficiaries who had been dis-
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charged from a hospital were rehospitalized within 
30 days, and 34.0 percent were rehospitalized within 
90 days. 
(6) The Medicare Payment Advisory Commis-
sion estimates that hospital readmissions cost Medi-
care approximately $15 billion per year, $12 billion 
of which is for cases considered preventable. 
(7) The MetLife Caregiving Cost Study dem-
onstrates that American businesses lose an esti-
mated $34 billion each year due to employees’ need 
to care for loved ones. 
(8) There are a number of care models that are 
designed to enhance coordination during transitions 
from care settings, including— 
(A) the Transitional Care Model; 
(B) the Care Transitions Intervention; 
(C) the Guided Care Model; 
(D) Project Boost; 
(E) Project Re-Engineered Discharge; and 
(F) the Enhanced Discharge Planning 
Program. 
(9) These care models and others have dem-
onstrated that effective care transitions lead to im-
provements in overall health care quality and result 
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in savings to patients and the United States health 
care system. 
(10) The Transitional Care Model, developed by 
the University of Pennsylvania, is a care manage-
ment strategy that identifies patients’ health goals, 
coordinates care throughout acute episodes of illness, 
develops a streamlined plan of care to prevent future 
hospitalizations, and prepares the beneficiary and 
family caregivers to implement this care plan. This 
model has shown through multiple randomized clin-
ical trials to produce significant health outcome im-
provements, reductions in health care costs among 
at-risk and chronically ill older adults, and increased 
patient satisfaction. 
(11) The Care Transitions Intervention, devel-
oped by Eric Coleman, is primarily a transitions 
self-management model that provides coaching, 
skills, and tools to help patients and caregivers as-
sert a more active role during transitions. This 
intervention has demonstrated lower rehospitaliza-
tion rates and lower hospital costs per patient. 
(12) The National Transitions of Care Coalition 
has developed the Transition of Care Compendium, 
providing a centralized resource for providers to ac-
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cess all currently available evidence-based interven-
tions and tools. 
SEC. 3. MEDICARE COVERAGE OF TRANSITIONAL CARE 
SERVICES. 
(a) COVERAGE.—Section 1861 of the Social Security 
Act (42 U.S.C. 1395x) is amended— 
(1) in subsection (s)(2)— 
(A) by striking ‘‘and’’ at the end of sub-
paragraph (EE); 
(B) by adding ‘‘and’’ at the end of sub-
paragraph (FF); and 
(C) by inserting after subparagraph (FF) 
the following new subparagraph: 
‘‘(GG) transitional care services (as defined in 
subsection (iii)(1));’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘Transitional Care Services 
‘‘(iii)(1) The term ‘transitional care services’ means 
services described in paragraph (2) furnished to a quali-
fied individual (described in paragraph (3)) by a transi-
tional care clinician (as defined in paragraph (4)) acting 
as an employee of (or pursuant to a contract with) a quali-
fied transitional care entity (as defined in paragraph (5)) 
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during the transitional care period (as defined in para-
graph (6)) for the qualified individual. 
‘‘(2) The services described in this paragraph are 
services that support a qualified individual during the 
transitional care period and include the following: 
‘‘(A) A comprehensive assessment of the indi-
vidual prior to the individual’s transition from one 
care facility to another care facility or home, includ-
ing an assessment of the individual’s physical and 
mental condition, cognitive and functional capacities, 
medication regimen and adherence, social and envi-
ronmental needs, and primary caregiver needs and 
resources. 
‘‘(B) Development of a comprehensive, evi-
denced-based plan of care for the individual devel-
oped with the individual and the individual’s primary 
caregiver and other health team members, identi-
fying potential health risks, treatment goals, current 
therapies, and future services for both the individual 
and any primary caregiver. 
‘‘(C) Development of a comprehensive medica-
tions management plan that ensures the safe use of 
medications and is based on the individual’s plan of 
care. Such management plan shall include the fol-
lowing: 
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‘‘(i) Identification of individual’s medica-
tions in use (including prescription and non- 
prescription medications). 
‘‘(ii) Assessment and (if needed) consulta-
tion with key medical providers to ensure medi-
cations are necessary, appropriate, and free of 
discrepancies. 
‘‘(iii) Assessment of the individual and 
family caregiver’s health literacy regarding the 
ability to properly follow medication instruc-
tions. 
‘‘(iv) Individual and family education and 
counseling about medications. 
‘‘(v) Teaching and counseling the indi-
vidual and the individual’s primary caregiver 
(as appropriate) to assure adherence to medica-
tions and other therapies and avoid adverse 
events. 
‘‘(D) Implementation of a plan to facilitate the 
safe transition of the individual from one level of 
care, care setting, or provider to another, which 
transition plan shall include at least the following: 
‘‘(i) A process to address the individual’s 
symptoms. 
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(B), progress in achieving such goals, and remaining 
treatment needs. 
‘‘(F) Other services that the Secretary deter-
mines are appropriate. 
The Secretary shall determine and update from time to 
time the services to be included in transitional care serv-
ices as appropriate, based on the evidence of their effec-
tiveness in reducing hospital readmissions and improving 
health outcomes. 
‘‘(3)(A) In this subsection, subject to subparagraph 
(C), the term ‘qualified individual’ means an individual 
who— 
‘‘(i) has been admitted to a subsection (d) hos-
pital (as defined for purposes of section 1886) for 
inpatient hospital services or to a critical care hos-
pital for inpatient critical access hospital services; 
and 
‘‘(ii) is identified by the Secretary as being at 
highest risk for readmission or for a poor transition 
from such a hospital to a posthospital site of care. 
‘‘(B) The identification under subparagraph (A)(ii) 
shall be based on achieving a minimum hierarchical condi-
tion category score (specified by the Secretary) in order 
to target eligibility benefits under this subsection to indi-
viduals with multiple chronic conditions and other risk fac-
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tors, such as cognitive impairment, depression, or a his-
tory of multiple hospitalizations. 
‘‘(C) After submitting to Congress the evaluation 
under section 2(d) of the Medicare Transitional Care Act 
of 2012 and considering any cost savings and quality im-
provements from the prior implementation of transitional 
care services under this title, the Secretary may expand 
eligibility of qualified individuals to include moderate-risk 
and lower-risk individuals, as determined in accordance 
with eligibility criteria specified by the Secretary. In ex-
panding eligibility, the Secretary may modify or scale 
transitional care services to meet the specific needs of 
moderate-risk and lower-risk individuals. 
‘‘(D) The Secretary shall ensure that qualified indi-
viduals receiving transitional care services are not receiv-
ing duplicative services under this title. 
‘‘(4)(A) The term ‘transitional care clinician’ means, 
with respect to a qualified individual, a nurse, case man-
ager, social worker, physician assistant, physician, phar-
macist, or other licensed health professional who— 
‘‘(i) has received specialized training in the clin-
ical care of people with multiple chronic conditions 
(including medication management) and communica-
tion and coordination with multiple providers of 
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services, suppliers, patients, and their primary care-
givers; 
‘‘(ii) is supported by an interdisciplinary team 
in a manner that assures continuity of care through-
out a transitional care period and across care set-
tings (including the residences of qualified individ-
uals); 
‘‘(iii) is employed by (or has a contract with) a 
qualified transitional care entity for the furnishing 
of transitional care services; and 
‘‘(iv) meets such participation criteria as the 
Secretary may specify consistent with this sub-
section. 
‘‘(B) In establishing participation criteria under sub-
paragraph (A)(iv), the Secretary shall assure that transi-
tional care clinicians meet relevant scope of practice and 
training requirements and have the ability to meet the in-
dividual needs of qualified individuals. 
‘‘(5) The term ‘qualified transitional care entity’ 
means— 
‘‘(A) a hospital or a critical care hospital; 
‘‘(B) a home health agency; 
‘‘(C) a primary care practice; 
‘‘(D) a federally qualified health center; 
‘‘(E) a long-term care facility; 
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‘‘(F) a medical home; 
‘‘(G) an appropriate community-based organiza-
tion described in section 3026(b)(1)(B) of the Pa-
tient Protection and Affordable Care Act (42 U.S.C. 
1395b–1 note); 
‘‘(H) an assisted living center; 
‘‘(I) an accountable care organization; and 
‘‘(J) another entity approved by the Secretary 
for purposes of this subsection. 
‘‘(6) The term ‘transitional care period’ means, with 
respect to a qualified individual, the period— 
‘‘(A) beginning on the date the individual is ad-
mitted to a subsection (d) hospital (as defined for 
purposes of section 1886) for inpatient hospital serv-
ices or is admitted to a critical care hospital for in-
patient critical access hospital services, for which 
payment may be made under this title; and 
‘‘(B) ending on the last day of the 90-day pe-
riod beginning on the date of the individual’s dis-
charge from such hospital or critical care hospital.’’. 
(b) PAYMENT AND PERFORMANCE MEASURES.—Sec-
tion 1833 of such Act (42 U.S.C. 1395l) is amended— 
(1) in subsection (a)(1), by striking ‘‘and’’ be-
fore ‘‘(Z)’’ and by inserting before the semicolon at 
the end the following: ‘‘, and (AA) with respect to 
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transitional care services (as defined in section 
1861(iii)(1)), the amounts paid shall be 100 percent 
of the amount determined under subsection (z)’’; 
(2) in the first sentence of subsection (b), by in-
serting ‘‘or transitional care services (as defined in 
section 1861(iii)(1))’’ after ‘‘(as defined in section 
1861(hh)(1))’’; and 
(3) by adding at the end the following new sub-
section: 
‘‘(z) PAYMENT AND PERFORMANCE MEASURES FOR 
TRANSITIONAL CARE SERVICES.— 
‘‘(1) PAYMENT.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
determine the method of payment for transi-
tional care services under this part, including 
appropriate risk adjustment that reflects the 
differences in resources needed to provide tran-
sitional care services to individuals with dif-
fering characteristics and circumstances and, 
when applicable, the performance measures 
under paragraph (3). The payment amount 
shall be sufficient to ensure the provision of 
necessary transitional care services throughout 
the transitional care period. The payment shall 
be structured in a manner to explicitly recog-
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