Patient Access to LTCH Care Act

Section 1886(m)(7) of the Social Security Act (42 U.S.C. 1395ww(m)(7)) is amended—

(1) in subparagraph (B)—

(A) by striking Notwithstanding subparagraph (A) and inserting the following:

Notwithstanding subparagraph (A)

(A) ; and

(B) by adding at the end the following new clause:

Notwithstanding clause (i)—

(I) in the case that application of such clause would result in a fixed loss amount established for fiscal year 2025 or 2026 that is greater than $50,000, the Secretary shall set such fixed loss amount for such fiscal year at $50,000; and

(II) in the case that application of such clause would result in a fixed loss amount established for fiscal year 2027 or a subsequent fiscal year that is greater than 110 percent of the fixed loss amount established for the preceding fiscal year, the Secretary shall set such fixed loss amount for such fiscal year at 110 percent of the fixed loss amount established for the preceding fiscal year.

(B) ; and

(2) in subparagraph (C), by striking reduction and inserting change.

Section 1886(m) of the Social Security Act (42 U.S.C. 1395ww(m)) is amended by adding at the end the following new paragraph:

For discharges occurring on or after October 1, 2025, or such earlier date as the Secretary may specify, the Secretary shall increase payment rates under the system described in paragraph (1) in accordance with subparagraph (B) to fully account for the higher costs associated with treating the highest complexity individuals.

In calculating payment rates under the system described in paragraph (1) for a discharge of an individual occurring on or after October 1, 2025 (or such earlier date as the Secretary may specify), the Secretary shall—

(i) in the case such individual had more than 5 major complications or comorbidities and fewer than 6 complications or comorbidities that were not major or had between 3 and 5 major complications and comorbidities and 5 or more complications and comorbidities that were not major (as demonstrated by claims data on the claim form submitted by the long-term care hospital), increase the payment weight for the applicable diagnosis-related group by 5 percent; and

(ii) in the case such individual had more than 5 major complications or comorbidities and more than 5 complications or comorbidities that were not major (as so demonstrated), increase the payment weight for the applicable diagnosis-related group by 10 percent.

The Secretary shall annually determine the impact of ICD–10 coding changes on aggregate spending as a result of the application of the payment increases under subparagraph (A) with respect to fiscal years 2026 through 2030.

The Secretary shall, at a time and in a manner determined appropriate by the Secretary, through notice and comment rulemaking, provide for one or more permanent increases or decreases to the standard prospective payment amount (or amounts) for fiscal years referenced in clause (i), on a prospective basis, to offset for increases or decreases in aggregate expenditures associated with coding changes attributable to the application of the payment increases under subparagraph (A).

The Secretary shall, at a time and in a manner determined appropriate by the Secretary, through notice and comment rulemaking, provide for one or more temporary increases or decreases to the standard prospective payment amount (or amounts) for fiscal years referenced in clause (i). Such a temporary increase or decrease shall apply only with respect to the fiscal year for which such temporary increase or decrease is made, and the Secretary shall not take into account such a temporary increase or decrease in computing such amount under this subsection for a subsequent fiscal year.

The additional payments resulting from the application of this paragraph shall not be implemented in a budget neutral manner.

(1) in subparagraph (A)—

(A) in clause (i), by striking and (G) and inserting (G), and (H);

(B) in clause (iii)(I), by inserting or, with respect to discharges from a long-term care hospital occurring on or after October 1, 2023, by a discharge from a stay in a critical access hospital, after from a subsection (d) hospital; and

(C) in clause (iv)(I), by inserting for discharges from a long-term care hospital occurring before October 1, 2023, before the stay in the long-term care hospital.

(2) by adding at the end the following new subparagraph:

For a discharge in a cost reporting period beginning on or after October 1, 2023, 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) meets either of the criteria described in clause (ii); and

(II) does not have a principal diagnosis relating to a psychiatric diagnosis or to rehabilitation.

For purposes of clause (i), the criteria described in this clause are, with respect to a discharge of an individual from a long-term care hospital, the following:

(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 or a critical access hospital and—

(aa) such individual was treated at the long-term care hospital for a severe wound (as defined in clause (iii));

(bb) such discharge from such long-term care hospital is assigned to Medicare-Severity-Long-Term-Care-Diagnosis-Related-Group (MS–LTC–DRG) 189 relating to pulmonary edema and respiratory failure (or any successor MS–LTC–DRG);

(cc) such discharge from such long-term care hospital is assigned to MS–LTC–DRG 871 relating to septicemia or severe sepsis without mechanical ventilation greater than 96 hours with major complications or comorbidities (or any successor MS–LTC–DRG); or

(dd) such individual was treated at the long-term care hospital for COVID–19.

(II) The discharge from such long-term care hospital is assigned to a MS–LTC–DRG with a relative weight that is equal to or greater than the specified amount (as defined in clause (iii)) for the fiscal year in which such discharge occurred.

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 a wound with morbid obesity, as identified by applicable codes on the claim from the long-term care hospital.

The term specified amount means, with respect to fiscal year, an amount equal to the 80th percentile of the relative weights for MS–LTC–DRGs that were assigned to primary diagnoses for all discharges occurring in the preceding fiscal year.

The term wound means as an injury involving division of tissue or rupture or the integument or mucous membrane with exposure to the external environment.