LTCH discharge payment percentage
(6) Application of site neutral IPPS payment rate in certain cases (A) General application of site neutral IPPS payment amount for discharges failing to meet applicable criteria (i) In general For a discharge in cost reporting periods beginning on or after October 1, 2015 , except as provided in clause (ii) and subparagraphs (C), (E), (F), and (G), payment under this subchapter to a long-term care hospital for inpatient hospital services shall be made at the applicable site neutral payment rate (as defined in subparagraph (B)). (ii) Exception for certain discharges meeting criteria Clause (i) shall not apply (and payment shall be made to a long-term care hospital without regard to this paragraph) for a discharge if— (I) the discharge meets the ICU criterion under clause (iii) or the ventilator criterion under clause (iv); and (II) the discharge does not have a principal diagnosis relating to a psychiatric diagnosis or to rehabilitation. (iii) Intensive care unit (ICU) criterion (I) In general The criterion specified in this clause (in this paragraph referred to as the “ICU criterion”), for a discharge from a long-term care hospital, is that the stay in the long-term care hospital ending with such discharge was immediately preceded by a discharge from a stay in a subsection (d) hospital that included at least 3 days in an intensive care unit (ICU), as determined by the Secretary. (II) Determining ICU days In determining intensive care unit days under subclause (I), the Secretary shall use data from revenue center codes 020x or 021x (or such successor codes as the Secretary may establish). (iv) Ventilator criterion The criterion specified in this clause (in this paragraph referred to as the “ventilator criterion”), for a discharge from a long-term care hospital, is that— (I) the stay in the long-term care hospital ending with such discharge was immediately preceded by a discharge from a stay in a subsection (d) hospital; and (II) the individual discharged was assigned to a Medicare-Severity-Long-Term-Care-Diagnosis-Related-Group (MS–LTC–DRG) based on the receipt of ventilator services of at least 96 hours. (B) Applicable site neutral payment rate defined (i) In general In this paragraph, the term “applicable site neutral payment rate” means— (I) for discharges in cost reporting periods beginning during fiscal years 2016 through 2019, the blended payment rate specified in clause (iii); and (II) for discharges in cost reporting periods beginning during fiscal year 2020 or a subsequent fiscal year, the site neutral payment rate (as defined in clause (ii)). (ii) Site neutral payment rate defined Subject to clause (iv), in this paragraph, the term “site neutral payment rate” means the lower of— (I) the IPPS comparable per diem amount determined under paragraph (d)(4) of section 412.529 of title 42, Code of Federal Regulations , including any applicable outlier payments under section 412.525 of such title; or (II) 100 percent of the estimated cost for the services involved. (iii) Blended payment rate The blended payment rate specified in this clause, for a long-term care hospital for inpatient hospital services for a discharge, is comprised of— (I) half of the site neutral payment rate (as defined in clause (ii)) for the discharge; and (II) half of the payment rate that would otherwise be applicable to such discharge without regard to this paragraph, as determined by the Secretary. (iv) Adjustment For each of fiscal years 2018 through 2026, the amount that would otherwise apply under clause (ii)(I) for the year (determined without regard to this clause) shall be reduced by 4.6 percent. (C) Limiting payment for all hospital discharges to site neutral payment rate for hospitals failing to meet applicable LTCH discharge thresholds (i) Notice of LTCH discharge payment percentage For cost reporting periods beginning during or after fiscal year 2016, the Secretary shall inform each long-term care hospital of its LTCH discharge payment percentage (as defined in clause (iv)) for such period. (ii) Limitation For cost reporting periods beginning during or after fiscal year 2020, if the Secretary determines for a long-term care hospital that its LTCH discharge payment percentage for the period is not at least 50 percent— (I) the Secretary shall inform the hospital of such fact; and (II) subject to clause (iii), for all discharges in the hospital in each succeeding cost reporting period, the payment amount under this subsection shall be the payment amount that would apply under subsection (d) for the discharge if the hospital were a subsection (d) hospital. (iii) Process for reinstatement The Secretary shall establish a process whereby a long-term care hospital may seek to and have the provisions of subclause (II) of clause (ii) discontinued with respect to that hospital. (iv) LTCH discharge payment percentage In this subparagraph, the term “LTCH discharge payment percentage” means, with respect to a long-term care hospital for a cost reporting period beginning during or after fiscal year 2020, the ratio (expressed as a percentage) of— (I) the number of Medicare fee-for-service discharges for such hospital and period for which payment is not made at the site neutral payment rate, to (II) the total number of Medicare fee-for-service discharges for such hospital and period. (D) Inclusion of subsection (d) Puerto Rico hospitals In this paragraph, any reference in this paragraph to a subsection (d) hospital shall be deemed to include a reference to a subsection (d) Puerto Rico hospital. (E) Temporary exception for certain severe wound discharges from certain long-term care hospitals (i) In general In the case of a discharge occurring prior to January 1, 2017 , subparagraph (A)(i) shall not apply (and payment shall be made to a long-term care hospital without regard to this paragraph) if such discharge— (I) is from a long-term care hospital that is— (aa) identified by the last sentence of subsection (d)(1)(B); and (bb) located in a rural area (as defined in subsection (d)(2)(D)) or treated as being so located pursuant to subsection (d)(8)(E); and (II) the individual discharged has a severe wound. (ii) Severe wound defined In this subparagraph, the term “severe wound” means a stage 3 wound, stage 4 wound, unstageable wound, non-healing surgical wound, infected wound, fistula, osteomyelitis, or wound with morbid obesity, as identified in the claim from the long-term care hospital. (F) Temporary exception for certain spinal cord specialty hospitals For discharges in cost reporting periods beginning during fiscal years 2018 and 2019, subparagraph (A)(i) shall not apply (and payment shall be made to a long-term care hospital without regard to this paragraph) if such discharge is from a long-term care hospital that meets each of the following requirements: (i) Not-for-profit The long-term care hospital was a not-for-profit long-term care hospital on June 1, 2014 , as determined by cost report data. (ii) Primarily providing treatment for catastrophic spinal cord or acquired brain injuries or other paralyzing neuromuscular conditions Of the discharges in calendar year 2013 from the long-term care hospital for which payment was made under this section, at least 50 percent were classified under MS–LTCH–DRGs 28, 29, 52, 57, 551, 573, and 963. (iii) Significant out-of-state admissions (I) In general The long-term care hospital discharged inpatients (including both individuals entitled to, or enrolled for, benefits under this subchapter and individuals not so entitled or enrolled) during fiscal year 2014 who had been admitted from at least 20 of the 50 States, determined by the States of residency of such inpatients and based on such data submitted by the hospital to the Secretary as the Secretary may require. (II) Implementation Notwithstanding any other provision of law, the Secretary may implement subclause (I) by program instruction or otherwise. (III) Non-application of Paperwork Reduction Act Chapter 35 of title 44 shall not apply to data collected under this clause. (G) Additional temporary exception for certain severe wound discharges from certain long-term care hospitals (i) In general For a discharge occurring in a cost reporting period beginning during fiscal year 2018, subparagraph (A)(i) shall not apply (and payment shall be made to a long-term care hospital without regard to this paragraph) if such discharge— (I) is from a long-term care hospital identified by the last sentence of subsection (d)(1)(B); (II) is classified under MS–LTCH–DRG 602, 603, 539, or 540; and (III) is with respect to an individual treated by a long-term care hospital for a severe wound. (ii) Severe wound defined In this subparagraph, the term “severe wound” means a wound which is a stage 3 wound, stage 4 wound, unstageable wound, non-healing surgical wound, or fistula as identified in the claim from the long-term care hospital. (iii) Wound defined In this subparagraph, the term “wound” means an injury involving division of tissue or rupture of the integument or mucous membrane with exposure to the external environment.