I 
113TH CONGRESS 
2D SESSION 
H. R. 4762 
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 
MAY 29, 2014 
Mr. BLUMENAUER (for himself and Mr. PETRI) introduced the following bill; 
which was referred to the Committee on Energy and Commerce, and in 
addition to the Committee on Ways and Means, for a period to be subse-
quently 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 2014’’. 
SEC. 2. FINDINGS. 
Congress finds the following: 
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(1) There are a number of care models that are 
designed to enhance coordination during transitions 
from care settings. 
(2) These care models and others have dem-
onstrated that effective care transitions lead to im-
provements in overall health care quality and result 
in savings to patients and the United States health 
care system. 
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: 
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‘‘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)) 
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 
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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: 
‘‘(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. 
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‘‘(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. 
‘‘(ii) An established process for the indi-
vidual and family caregivers to receive timely 
access to key health care providers during an 
episode of care as required by the individual’s 
condition. 
‘‘(iii) An established process for commu-
nicating with the individual, family caregivers, 
and other health care providers posttransition 
from an episode of care. 
‘‘(iv) A system that ensures ownership, re-
sponsibility, and accountability for the care of 
the individual at all times, including identifying 
and documenting any family caregiver (or care-
givers) that exist. 
‘‘(v) Providing information and resources 
about condition and care choices to adequately 
prepare the individual and caregivers for in-
formed decisionmaking. 
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‘‘(E) Providing to the qualified individual, pri-
mary caregiver, and appropriate clinicians and the 
qualified transitional care entity providing ongoing 
care at the conclusion of the transitional care period, 
a written summary that includes the goals estab-
lished in the plan of care described in subparagraph 
(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 
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‘‘(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-
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 2014 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. 
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‘‘(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 
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 
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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 or rural 
health clinic; 
‘‘(E) a long-term care facility; 
‘‘(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-
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patient critical access hospital services, for which 
payment may be made under this title; and 
‘‘(B) ending on the last day of the 45-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 the Social Security 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 
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-
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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-
nize transitional care as an episode of services 
that crosses multiple care settings, providers of 
services, and suppliers. The payment with re-
spect to transitional care services furnished by 
a transitional care clinician shall be made, not-
withstanding any other provision of this title, to 
the qualified transitional care entity which em-
ploys, or has a contract with, the clinician for 
the furnishing of such services. 
‘‘(B) HIT 
INCENTIVE
PAYMENT.—The 
Secretary may provide for an additional pay-
ment with respect to transitional care services 
to encourage transitional care clinicians and 
qualified transitional care entities to use health 
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information technology in the provision of such 
services. 
‘‘(C) NO
PAYMENT
FOR
REQUIRED
DIS-
CHARGE PLANNING SERVICES.—Payment shall 
not be made for transitional care services under 
this subsection for an entity insofar as such 
services are otherwise required to be provided 
through the discharge planning process under 
section 1861(ee) or under conditions of partici-
pation for the entity under section 1866. 
‘‘(2) PERFORMANCE MEASURES.— 
‘‘(A) ACCOUNTABILITY.— 
‘‘(i) IN
GENERAL.—The Secretary 
shall establish a method whereby qualified 
transitional care entities responsible for 
furnishing transitional care services are 
held accountable for process and outcome 
based on performance measures specified 
by the Secretary from those that have been 
endorsed by the National Quality Forum 
or similar standard-setting organization or 
are otherwise used in other quality pro-
grams under this title or title XIX. 
‘‘(ii) DEVELOPMENT
AND
ENDORSE-
MENT OF PERFORMANCE MEASURE SET.— 
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For purposes of carrying out clause (i), the 
Secretary shall enter into an arrange-
ment— 
‘‘(I) with the National Quality 
Forum for the evaluation, endorse-
ment, and recommendation of addi-
tional performance measures for tran-
sitional care services and to identify 
remaining gaps in available measures, 
including measures to both the send-
ing and receiving side of the transi-
tion; and 
‘‘(II) 
with 
the 
Agency 
for 
Healthcare Research and Quality to 
support measure development, to fill 
gaps in available measures, to conduct 
comparative effectiveness research of 
transitional care models and tools, 
and to provide for the ongoing main-
tenance of the set of performance 
measures for transitional care serv-
ices. 
‘‘(B) PAY FOR PERFORMANCE.—As soon 
as practicable after reliable process and out-
come performance measures have been endorsed 
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and specified under subparagraph (A), the Sec-
retary shall provide that the payment amounts 
under paragraph (1) for transitional care serv-
ices shall be linked to performance on such 
measures. 
‘‘(C) PUBLIC REPORTING.—The Secretary 
shall establish a mechanism to publicly report 
on a qualifying transitional care entity’s per-
formance on such measures, including providing 
benchmarks to identify high performers and 
those practices that contribute to lower hospital 
readmission rates. 
‘‘(D) DISSEMINATION OF INFORMATION ON 
BEST PRACTICES.—The Secretary shall dissemi-
nate information on best practices used by tran-
sitional care clinicians and qualified transitional 
care entities in furnishing transitional care 
services for purposes of application in other set-
tings, such as in conditions of participation 
under this title, under the Quality Improvement 
Organization Program under part B of title XI, 
and public-private quality alliances, such as the 
Hospital Quality Alliance. 
‘‘(3) PREVENTION OF INAPPROPRIATE STEER-
ING.—The Secretary shall promulgate such regula-
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tions as the Secretary deems necessary to address 
any protections needed, beyond those otherwise pro-
vided under law and regulations, to prevent inappro-
priate steering of qualified individuals to providers 
of services, suppliers, qualified transitional care enti-
ties, or transitional care clinicians, under this part 
or inappropriate limitations on access to needed 
transitional care services under this part.’’. 
(c) COORDINATION WITH HOSPITAL DISCHARGE 
PLANNING.—Section 1861(ee)(2) of the Social Security 
Act (42 U.S.C. 1395x(ee)(2)) is amended by adding at 
the end the following: 
‘‘(I) In the case of subsection (d) hospitals 
and critical care hospitals, the hospital must— 
‘‘(i) identify, as soon as practicable 
after admission, those patients who are 
qualified individuals described in para-
graph (3) of section 1861(iii); and 
‘‘(ii) provide to such patients and 
their primary caregivers a list of transi-
tional care entities available under such 
section to arrange for the provision of 
transitional care services, a list of transi-
tional care services provided under this 
part, and a notice that the transitional 
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care service benefit under such section is 
provided to qualified individuals with no 
deductible or cost sharing. 
Nothing in subparagraph (I) shall be construed 
as preventing a hospital or critical care hospital 
from entering into an agreement with a quali-
fied transitional care entity or a transitional 
care clinician for the furnishing of transitional 
care services to the hospital’s patients.’’. 
(d) EVALUATION; REPORT.— 
(1) IN GENERAL.—The Secretary of Health and 
Human Services shall evaluate the performance of 
the transitional care benefit under the amendments 
made by this section by measuring the following, 
both for individuals receiving transitional care serv-
ices and for individuals not receiving such services: 
(A) Admission rates to health care facili-
ties. 
(B) Hospital readmission rates. 
(C) Cost of transitional care and all other 
health care services. 
(D) Quality of transitional care experi-
ences. 
(E) Measures of quality and efficiency. 
(F) Beneficiary experience. 
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(G) Health outcomes. 
(H) Reductions in expenditures under this 
title over time. 
(2) REPORT.—The Secretary shall submit a re-
port to Congress no later than April 1, 2018, on the 
performance measures achieved by the transitional 
care benefit in the first 2 years of implementation. 
After submitting such report, the Secretary may ex-
pand the benefit to moderate-risk and lower-risk in-
dividuals under section 1861(iii)(3)(B) of the Social 
Security Act, as added by subsection (a). 
(e) EFFECTIVE DATE.—The amendments made by 
this section shall apply to services furnished on or after 
January 1, 2015. 
Æ 
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