I 
117TH CONGRESS 
1ST SESSION H. R. 4890 
To amend title XVIII of the Social Security Act to establish a program 
to allow qualified group practices to furnish certain items and services 
at qualified skilled nursing facilities to individuals entitled to benefits 
under part A and enrolled under part B of the Medicare program 
to reduce unnecessary hospitalizations, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JULY 30, 2021 
Ms. KUSTER (for herself and Mr. SMITH of Nebraska) introduced the fol-
lowing bill; which was referred to the Committee on Ways and Means, 
and in addition to the Committee on Energy and Commerce, for a period 
to be subsequently determined by the Speaker, in each case for consider-
ation of such provisions as fall within the jurisdiction of the committee 
concerned 
A BILL 
To amend title XVIII of the Social Security Act to establish 
a program to allow qualified group practices to furnish 
certain items and services at qualified skilled nursing 
facilities to individuals entitled to benefits under part 
A and enrolled under part B of the Medicare program 
to reduce unnecessary hospitalizations, and for other pur-
poses. 
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 ‘‘Reducing Unnecessary 
Senior Hospitalizations Act of 2021’’ or the ‘‘RUSH Act 
of 2021’’. 
SEC. 2. SNF-BASED PROVISION OF PREVENTIVE ACUTE 
CARE AND HOSPITALIZATION REDUCTION 
PROGRAM. 
Title XVIII of the Social Security Act is amended by 
adding at the end the following new section: 
‘‘SEC. 
1899C. 
SNF-BASED 
PROVISION 
OF 
PREVENTIVE 
ACUTE CARE AND HOSPITALIZATION REDUC-
TION PROGRAM. 
‘‘(a) ESTABLISHMENT.—There is established a pro-
gram to be known as the ‘SNF-based Provision of Preven-
tive Acute Care and Hospitalization Reduction Program’ 
(in this section referred to as the ‘Program’), to be admin-
istered by the Secretary, for purposes of reducing unneces-
sary hospitalizations and emergency department visits by 
allowing qualified group practices (as defined in section 
1877(h)(4)) on or after January 1, 2022, to furnish items 
and services identified under subsection (b)(3) to individ-
uals entitled to benefits under part A and enrolled under 
part B residing in qualified skilled nursing facilities. 
‘‘(b) OPERATION
OF PROGRAM.—Under the Pro-
gram, the Secretary shall provide for the following: 
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‘‘(1) Certification of skilled nursing facilities as 
qualified skilled nursing facilities under subsection 
(c)(1). 
‘‘(2) Certification of group practices as quali-
fied group practices under subsection (c)(2). 
‘‘(3) Identification on an annual basis of min-
imum required, clinically appropriate nonsurgical 
items and services furnished at a hospital emergency 
department that may be safely furnished by a quali-
fied group practice at a qualified skilled nursing fa-
cility under the Program and that such qualified 
group practice shall offer to furnish under the Pro-
gram. Such items and services may include provider 
review of lab and imaging reports for medical deci-
sion making, medication management, blood glucose 
management, behavioral health services, and other 
services offered to diagnose or treat low acuity con-
ditions. 
‘‘(4) Establishment of qualifications for non-
physician employees who may furnish such items 
and services at a qualified skilled nursing facility. 
Such qualifications shall include the requirement 
that such an employee— 
‘‘(A) be certified in basic life support by a 
nationally recognized specialty board of certifi-
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cation or equivalent certification board, in ac-
cordance with requirements under section 
483.24(a)(3) of title 42, Code of Federal Regu-
lations (or any successor regulation); and 
‘‘(B) have— 
‘‘(i) 
clinical 
experience 
furnishing 
medical care— 
‘‘(I) in a skilled nursing facility; 
‘‘(II) in a hospital emergency de-
partment setting; or 
‘‘(III) as an employee of a pro-
vider or supplier of ambulance serv-
ices; or 
‘‘(ii) a certification in paramedicine. 
‘‘(5) Payment under this title for items and 
services identified under paragraph (3) furnished by 
such qualified group practices at such a facility in 
amounts determined under subsection (d). 
‘‘(c) CERTIFICATIONS.— 
‘‘(1) QUALIFIED
SKILLED
NURSING
FACILI-
TIES.— 
‘‘(A) IN GENERAL.—For purposes of this 
section, the Secretary shall certify a skilled 
nursing facility as a qualified skilled nursing fa-
cility if the facility submits an application in a 
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time and manner specified by the Secretary and 
meets the following requirements: 
‘‘(i) The facility has on-site diagnostic 
equipment necessary for a qualified group 
practice to furnish items and services 
under the Program and real-time audio 
and visual capabilities as provided by the 
agreement between the facility and the 
qualified group practice. 
‘‘(ii) The facility has at least one indi-
vidual who meets the qualifications de-
scribed in subsection (b)(4) or a physician 
present 24 hours a day and 7 days a week 
to work with the qualified group practice, 
in accordance with section 483.35(a) of 
title 42, Code of Federal Regulations (or 
any successor regulation). Such individual 
may be a member of the staff of the quali-
fied skilled nursing facility or of the quali-
fied group practice. 
‘‘(iii) The facility ensures that resi-
dents of such facility, upon entering such 
facility, are allowed to specify in an ad-
vanced care directive or otherwise docu-
mented in the individual’s records whether 
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the resident wishes to receive items and 
services furnished at the facility under the 
Program in a case where communication 
with the resident is not possible. 
‘‘(iv) The facility ensures that individ-
uals to be furnished such items and serv-
ices under the Program at such facility 
have the opportunity, at their request, to 
instead be transported to a hospital emer-
gency department. 
‘‘(v) The facility is not part of the 
Special Focus Facility program of the Cen-
ters for Medicare & Medicaid Services (al-
though the facility may, at the discretion 
of the Secretary, be a candidate for selec-
tion under such program). 
‘‘(B) REQUIRED PROVISION OF SERVICES 
AND
ACTIVITIES.—Nothing in this paragraph 
shall affect the application of requirements 
under section 1819(b)(4), relating to provision 
of services and activities, to a facility. 
‘‘(2) QUALIFIED GROUP PRACTICES.—For pur-
poses of this section, the Secretary shall certify a 
group practice as a qualified group practice for a pe-
riod of 3 years if the group practice submits an ap-
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plication in a time and manner specified by the Sec-
retary and meets the following requirements: 
‘‘(A) The group practice offers to furnish 
all minimum required items and services identi-
fied under subsection (b)(3) under the Pro-
gram. 
‘‘(B) The group practice submits a notifi-
cation to the Secretary annually specifying 
which (if any) additional items and services 
identified under subsection (b)(3) for a year the 
group practice will offer to furnish for such 
year under the Program. 
‘‘(C) The group practice ensures that only 
individuals who meet the qualifications estab-
lished under subsection (b)(4) or a physician 
who is part of such group practice may furnish 
such minimum required items and services and 
such additional items and services. 
‘‘(D) The group practice, as provided by 
the agreement between the facility and the 
group practice or under the supervision of the 
medical director of the facility, ensures that, in 
the case where such minimum required items 
and services or such additional items and serv-
ices are furnished by such an individual, such 
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individual furnishes such minimum required 
items and services or additional items and serv-
ices under the supervision, either in-person or 
through the use of telehealth (not including 
store-and-forward technologies), of— 
‘‘(i) a physician— 
‘‘(I) who is board certified or 
board eligible in emergency medicine, 
family medicine, geriatrics, or internal 
medicine; or 
‘‘(II) who has been certified by a 
nationally recognized specialty board 
of certification or equivalent certifi-
cation board in basic life support; 
‘‘(ii) a nurse practitioner who has 
been certified by a nationally recognized 
specialty board of certification or equiva-
lent certification board in basic life sup-
port; or 
‘‘(iii) a physician assistant who has 
been certified by a nationally recognized 
specialty board of certification or equiva-
lent certification board in basic life sup-
port. 
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‘‘(E) With respect to any year in which the 
qualified group practice would participate in the 
Program, the Chief Actuary for the Centers for 
Medicare & Medicaid Services determines that 
such participation during such year will not re-
sult in total estimated expenditures under this 
title for such year being greater than total esti-
mated expenditures under such title for such 
year without such participation. 
‘‘(d) PAYMENTS AND TREATMENT OF SAVINGS.— 
‘‘(1) PAYMENTS.— 
‘‘(A) IN GENERAL.—For 2022 and each 
subsequent year, payments shall continue to be 
made to qualified group practices and qualified 
skilled nursing facilities participating in the 
Program under the original Medicare fee-for- 
service program under parts A and B in the 
same manner as they would otherwise be made 
except that such group practices and skilled 
nursing facilities are eligible to receive payment 
for shared savings under paragraph (2) if they 
meet the requirement under subparagraph 
(B)(i). 
‘‘(B) SAVINGS REQUIREMENT AND BENCH-
MARK.— 
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‘‘(i) DETERMINING SAVINGS.—In each 
year of the Program, a qualified group 
practice (and any qualified skilled nursing 
facility participating in the Program that 
has an agreement with the group practice 
for the furnishing of items and services 
identified under subsection (b)(3) to resi-
dents of the facility) shall be eligible to re-
ceive payment for shared savings under 
paragraph (2) only if the estimated aver-
age per capita Medicare expenditures for 
Medicare fee-for-service beneficiaries for 
parts A and B services furnished under the 
Program by the group practice (and any 
such facility), adjusted for beneficiary 
characteristics, is at least the percent spec-
ified by the Secretary below the applicable 
benchmark under clause (ii). The Sec-
retary shall determine the appropriate per-
cent described in the preceding sentence to 
account for normal variation in expendi-
tures under this title, based upon the num-
ber of Medicare fee-for-service beneficiaries 
participating in the Program. 
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‘‘(ii) 
ESTABLISH
AND
UPDATE 
BENCHMARK.—For each qualified group 
practice (and any qualified skilled nursing 
facility participating in the Program that 
has an agreement with the group practice 
for the furnishing of items and services 
identified under subsection (b)(3) to resi-
dents of the facility) the Secretary shall es-
timate a single benchmark for each year 
that is applicable to both the group prac-
tice (and any such facility) using the most 
recent available 3 years of per-beneficiary 
expenditures for parts A and B services for 
Medicare fee-for-service beneficiaries for 
items and services furnished by such group 
practice or skilled nursing facility under 
the Program. Such benchmark shall be ad-
justed for beneficiary characteristics and 
such other factors as the Secretary deter-
mines appropriate. Such benchmark shall 
be reset at the start of each year. 
‘‘(2) PAYMENTS FOR SHARED SAVINGS.—If a 
qualified group practice (and any qualified skilled 
nursing facility participating in the Program that 
has an agreement with the group practice for the 
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furnishing of items and services identified under 
subsection (b)(3) to residents of the facility) meets 
the requirements under paragraph (1), the Secretary 
shall— 
‘‘(A) pay to such qualified group practice 
an amount equal to 37.5 percent of the dif-
ference between such estimated average per 
capita Medicare expenditures in a year, ad-
justed for beneficiary characteristics, for items 
and services furnished under the Program by 
the group practice (and any such facility) and 
such benchmark for the qualified group practice 
(and any such facility); and 
‘‘(B) in the case of each such facility— 
‘‘(i) if the qualified skilled nursing fa-
cility has at least a three-star rating under 
the Five Star Quality Rating System (or a 
successor system), pay to the facility an 
amount that bears the same ratio to 12.5 
percent of the estimated amount of such 
difference as the amount of expenditures 
under the Program for such items and 
services furnished with respect to individ-
uals at such facility by such qualified 
group practice during such year bears to 
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the total amount of expenditures under the 
Program for such items and services fur-
nished with respect to all individuals by 
such qualified group practice during such 
year; and 
‘‘(ii) in the case of a qualified skilled 
nursing facility that is not described in 
clause (i), retain in the Federal Hospital 
Insurance Trust Fund under section 1817 
the amount that the facility would have 
been paid pursuant to clause (i) if the fa-
cility were described in such clause until 
such time as the facility has at least a 
three-star rating under the Five Star Qual-
ity Rating System (or a successor system), 
at which point the Secretary shall pay such 
amount to the facility. 
‘‘(3) ADVANCED ALTERNATIVE PAYMENT MOD-
ELS.—Paragraph (2) shall not apply to items and 
services furnished to an individual entitled to bene-
fits under part A and enrolled under Part B for 
whom shared savings would otherwise be attributed 
through an advanced alternative payment model as 
authorized under section 1115A or section 1899. 
‘‘(e) EVALUATION.— 
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‘‘(1) IN GENERAL.—With respect to a qualified 
group practice and a qualified skilled nursing facil-
ity, not later than 6 months after such group prac-
tice begins furnishing items and services under the 
Program (or, in the case of a qualified skilled nurs-
ing facility, not less than 6 months after a qualified 
group practice first furnishes such items and serv-
ices at such facility), and not less than once every 
2 years thereafter, the Secretary shall evaluate such 
qualified group practice and such qualified facility 
using information received under paragraph (2) on 
such criteria as determined appropriate by the Sec-
retary. 
‘‘(2) REPORTING OF PERFORMANCE AND QUAL-
ITY IMPROVEMENTS.—In a time and manner speci-
fied by the Secretary, a qualified group practice and 
a qualified skilled nursing facility shall submit to the 
Secretary a report containing the following informa-
tion with respect to items and services furnished 
under the Program during a reporting period (as 
specified by the Secretary): 
‘‘(A) The items and services most fre-
quently furnished under the Program in such 
period. 
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‘‘(B) The number of individuals with re-
spect to whom such group practice furnished 
such items and services in such period (or, in 
the case of a qualified skilled nursing facility, 
the number of individuals with respect to whom 
such a group practice furnished such items and 
services at such facility in such period). 
‘‘(C) The number of hospitalizations pre-
vented under the Program in such period. 
‘‘(D) The number of such individuals who 
were admitted to a hospital or treated in the 
emergency department of a hospital within 24 
hours of being furnished such items and serv-
ices. 
‘‘(E) Other information determined appro-
priate by the Secretary. 
‘‘(3) LOSS OF QUALIFIED CERTIFICATION.— 
‘‘(A) IN
GENERAL.—Not later than 3 
months after a determination described in this 
sentence is made, the Secretary may revoke the 
certification of a qualified skilled nursing facil-
ity or a qualified group practice made under 
subsection (c) if— 
‘‘(i) the Chief Actuary of the Centers 
for Medicare & Medicaid Services deter-
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mines that the participation of such skilled 
nursing facility or such group practice in 
the Program during a year resulted in 
total expenditures under this title for such 
period being greater than total expendi-
tures under such title would have been 
during such period without such participa-
tion; or 
‘‘(ii) a facility is selected for the Spe-
cial Focus Facility program or, if the facil-
ity is a candidate for the Special Focus 
Facility program, the Secretary determines 
that the participation of such facility in the 
Program should be terminated. 
‘‘(B) EXCLUSION FROM CERTIFICATION.— 
‘‘(i) IN GENERAL.—In the case that 
the Secretary revokes the certification of a 
qualified skilled nursing facility or a quali-
fied group practice under subparagraph 
(A), such skilled nursing facility or such 
group practice shall be ineligible for certifi-
cation as a qualified skilled nursing facility 
or a qualified group practice (as applica-
ble) under subsection (c) for the applicable 
period (as defined under clause (ii)). 
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‘‘(ii) 
APPLICABLE
PERIOD
DE-
FINED.—In this subparagraph, the term 
‘applicable period’ means— 
‘‘(I) if the revocation of a facility 
or group practice under subparagraph 
(A) is due to the application of clause 
(i) of such subparagraph, a 1-year pe-
riod beginning on the date of such 
revocation; and 
‘‘(II) in the revocation of a facil-
ity under subparagraph (A) is due to 
the application of clause (ii) of such 
subparagraph, the period beginning 
on the date of such revocation and 
ending on the date on which the facil-
ity graduates from the Special Focus 
Facility program (or, in the case of a 
facility that is a candidate for such 
program, the date on which the facil-
ity is no longer such a candidate, as 
determined by the Secretary). 
‘‘(f) DETERMINATION
OF BUDGET NEUTRALITY; 
TERMINATION OF PROGRAM.— 
‘‘(1) DETERMINATION.—Not later than July 1, 
2027, the Chief Actuary of the Centers for Medicare 
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& Medicaid Services shall determine whether the 
Program has resulted in an increase in total expend-
itures under this title with respect to the period be-
ginning on January 1, 2022, and ending on Decem-
ber 31, 2026, compared to what such expenditures 
would have been during such period had the Pro-
gram not been in operation. 
‘‘(2) TERMINATION.—If the Chief Actuary 
makes a determination under paragraph (1) that the 
Program has resulted in an increase in total expend-
itures under this title, the Secretary shall terminate 
the Program as of January 1 of the first year begin-
ning after such determination.’’. 
Æ 
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