Title 42, The Public Health and WelfareRelease 119-110
§1395cc–4 National Pilot Program on Payment Bundling
Title 42 › CHAPTER 7 — SOCIAL SECURITY › SUBCHAPTER XVIII — HEALTH INSURANCE FOR AGED AND DISABLED › Part E — Miscellaneous Provisions › § 1395cc–4
Summary
The Secretary must set up a pilot program to test bundled, coordinated care for Medicare patients around a hospital stay. The program focuses on people who have Part A and Part B only (not Part C or PACE) and who are admitted for one of 10 conditions the Secretary picks. An “episode of care” normally means the 3 days before hospital admission, the hospital stay, and the 30 days after discharge, though the Secretary can set a different period. The Secretary must pick a patient assessment tool, make site-neutral quality measures for episodes and post-acute care with AHRQ help, and start the program by January 1, 2013. The pilot lasts 5 years but may be expanded after January 1, 2016 if the Secretary finds it will cut spending or improve care, the Chief Actuary certifies it would save money, and it won’t limit benefits. Groups of providers (hospitals, doctor groups, skilled nursing, home health, etc.) can apply to join. The Secretary will test payment methods, including bundled payments paid to the participating group, and must set payments so they do not increase Medicare spending versus what would have happened otherwise. Payments should cover inpatient, physician, outpatient, post-acute care (home health, skilled nursing, rehab, long-term care hospital), and care coordination tasks. Participants must report yearly on quality measures. The Secretary may waive rules as needed, must run an independent evaluation, must report interim results 2 years after starting and final results 3 years after, must consult small rural hospitals, and must separately test a continuing care hospital model. Chapter 35 of Title 44 does not apply to selecting or testing models under the pilot.
Full Legal Text
Title 42, §1395cc–4
The Public Health and Welfare, Source: USLM XML via OLRC
(a)Implementation
(1)In general
The Secretary shall establish a pilot program for integrated care during an episode of care provided to an applicable beneficiary around a hospitalization in order to improve the coordination, quality, and efficiency of health care services under this subchapter.
(2)Definitions
In this section: (A) Applicable beneficiary
(B)Applicable condition
The term “applicable condition” means 1 or more of 10 conditions selected by the Secretary. In selecting conditions under the preceding sentence, the Secretary shall take into consideration the following factors:
(i)Whether the conditions selected include a mix of chronic and acute conditions.
(ii)Whether the conditions selected include a mix of surgical and medical conditions.
(iii)Whether a condition is one for which there is evidence of an opportunity for providers of services and suppliers to improve the quality of care furnished while reducing total expenditures under this subchapter.
(iv)Whether a condition has significant variation in—
(I)the number of readmissions; and
(II)the amount of expenditures for post-acute care spending under this subchapter.
(v)Whether a condition is high-volume and has high post-acute care expenditures under this subchapter.
(vi)Which conditions the Secretary determines are most amenable to bundling across the spectrum of care given practice patterns under this subchapter.
(C)Applicable services
The term “applicable services” means the following:
(i)Acute care inpatient services.
(ii)Physicians’ services delivered in and outside of an acute care hospital setting.
(iii)Outpatient hospital services, including emergency department services.
(iv)Post-acute care services, including home health services, skilled nursing services, inpatient rehabilitation services, and inpatient hospital services furnished by a long-term care hospital.
(v)Other services the Secretary determines appropriate.
(D)Episode of care
(i)In general
Subject to clause (ii), the term “episode of care” means, with respect to an applicable condition and an applicable beneficiary, the period that includes—
(I)the 3 days prior to the admission of the applicable beneficiary to a hospital for the applicable condition;
(II)the length of stay of the applicable beneficiary in such hospital; and
(III)the 30 days following the discharge of the applicable beneficiary from such hospital.
(ii)Establishment of period by the Secretary
The Secretary, as appropriate, may establish a period (other than the period described in clause (i)) for an episode of care under the pilot program.
(E)Physicians’ services
The term “physicians’ services” has the meaning given such term in section 1395x(q) of this title.
(F)Pilot program
The term “pilot program” means the pilot program under this section.
(G)Provider of services
The term “provider of services” has the meaning given such term in section 1395x(u) of this title.
(H)Readmission
The term “readmission” has the meaning given such term in section 1395ww(q)(5)(E) of this title.
(I)Supplier
The term “supplier” has the meaning given such term in section 1395x(d) of this title.
(3)Deadline for implementation
The Secretary shall establish the pilot program not later than January 1, 2013.
(b)Developmental phase
(1)Determination of patient assessment instrument
The Secretary shall determine which patient assessment instrument (such as the Continuity Assessment Record and Evaluation (CARE) tool) shall be used under the pilot program to evaluate the applicable condition of an applicable beneficiary for purposes of determining the most clinically appropriate site for the provision of post-acute care to the applicable beneficiary.
(2)Development of quality measures for an episode of care and for post-acute care
(A)In general
The Secretary, in consultation with the Agency for Healthcare Research and Quality and the entity with a contract under section 1395aaa(a) of this title, shall develop quality measures for use in the pilot program—
(i)for episodes of care; and
(ii)for post-acute care.
(B)Site-neutral post-acute care quality measures
Any quality measures developed under subparagraph (A)(ii) shall be site-neutral.
(C)Coordination with quality measure development and endorsement procedures
The Secretary shall ensure that the development of quality measures under subparagraph (A) is done in a manner that is consistent with the measures developed and endorsed under section 1395aaa and 1395aaa–1 of this title that are applicable to all post-acute care settings.
(c)Details
(1)Duration
(A)In general
Subject to subparagraph (B), the pilot program shall be conducted for a period of 5 years.
(B)Expansion
The Secretary may, at any point after January 1, 2016, expand the duration and scope of the pilot program, to the extent determined appropriate by the Secretary, if—
(i)the Secretary determines that such expansion is expected to—
(I)reduce spending under this subchapter without reducing the quality of care; or
(II)improve the quality of care and reduce spending;
(ii)the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such expansion would reduce program spending under this subchapter; and
(iii)the Secretary determines that such expansion would not deny or limit the coverage or provision of benefits under this subchapter for individuals.
(2)Participating providers of services and suppliers
(A)In general
An entity comprised of providers of services and suppliers, including a hospital, a physician group, a skilled nursing facility, and a home health agency, who are otherwise participating under this subchapter, may submit an application to the Secretary to provide applicable services to applicable individuals under this section.
(B)Requirements
The Secretary shall develop requirements for entities to participate in the pilot program under this section. Such requirements shall ensure that applicable beneficiaries have an adequate choice of providers of services and suppliers under the pilot program.
(3)Payment methodology
(A)In general
(i)Establishment of payment methods
The Secretary shall develop payment methods for the pilot program for entities participating in the pilot program. Such payment methods may include bundled payments and bids from entities for episodes of care. The Secretary shall make payments to the entity for services covered under this section.
(ii)No additional program expenditures
Payments under this section for applicable items and services under this subchapter (including payment for services described in subparagraph (B)) for applicable beneficiaries for a year shall be established in a manner that does not result in spending more for such entity for such beneficiaries than would otherwise be expended for such entity for such beneficiaries for such year if the pilot program were not implemented, as estimated by the Secretary.
(B)Inclusion of certain services
A payment methodology tested under the pilot program shall include payment for the furnishing of applicable services and other appropriate services, such as care coordination, medication reconciliation, discharge planning, transitional care services, and other patient-centered activities as determined appropriate by the Secretary.
(C)Bundled payments
(i)In general
A bundled payment under the pilot program shall—
(I)be comprehensive, covering the costs of applicable services and other appropriate services furnished to an individual during an episode of care (as determined by the Secretary); and
(II)be made to the entity which is participating in the pilot program.
(ii)Requirement for provision of applicable services and other appropriate services
Applicable services and other appropriate services for which payment is made under this subparagraph shall be furnished or directed by the entity which is participating in the pilot program.
(D)Payment for post-acute care services after the episode of care
The Secretary shall establish procedures, in the case where an applicable beneficiary requires continued post-acute care services after the last day of the episode of care, under which payment for such services shall be made.
(4)Quality measures
(A)In general
The Secretary shall establish quality measures (including quality measures of process, outcome, and structure) related to care provided by entities participating in the pilot program. Quality measures established under the preceding sentence shall include measures of the following:
(i)Functional status improvement.
(ii)Reducing rates of avoidable hospital readmissions.
(iii)Rates of discharge to the community.
(iv)Rates of admission to an emergency room after a hospitalization.
(v)Incidence of health care acquired infections.
(vi)Efficiency measures.
(vii)Measures of patient-centeredness of care.
(viii)Measures of patient perception of care.
(ix)Other measures, including measures of patient outcomes, determined appropriate by the Secretary.
(B)Reporting on quality measures
(i)In general
A entity shall submit data to the Secretary on quality measures established under subparagraph (A) during each year of the pilot program (in a form and manner, subject to clause (iii), specified by the Secretary).
(ii)Submission of data through electronic health record
To the extent practicable, the Secretary shall specify that data on measures be submitted under clause (i) through the use of an qualified electronic health record (as defined in section 300jj(13) of this title) in a manner specified by the Secretary.
(d)Waiver
The Secretary may waive such provisions of this subchapter and subchapter XI as may be necessary to carry out the pilot program.
(e)Independent evaluation and reports on pilot program
(1)Independent evaluation
The Secretary shall conduct an independent evaluation of the pilot program, including the extent to which the pilot program has—
(A)improved quality measures established under subsection (c)(4)(A);
(B)improved health outcomes;
(C)improved applicable beneficiary access to care; and
(D)reduced spending under this subchapter.
(2)Reports
(A)Interim report
Not later than 2 years after the implementation of the pilot program, the Secretary shall submit to Congress a report on the initial results of the independent evaluation conducted under paragraph (1).
(B)Final report
Not later than 3 years after the implementation of the pilot program, the Secretary shall submit to Congress a report on the final results of the independent evaluation conducted under paragraph (1).
(f)Consultation
The Secretary shall consult with representatives of small rural hospitals, including critical access hospitals (as defined in section 1395x(mm)(1) of this title), regarding their participation in the pilot program. Such consultation shall include consideration of innovative methods of implementing bundled payments in hospitals described in the preceding sentence, taking into consideration any difficulties in doing so as a result of the low volume of services provided by such hospitals.
(g)Application of pilot program to continuing care hospitals
(1)In general
In conducting the pilot program, the Secretary shall apply the provisions of the program so as to separately pilot test the continuing care hospital model.
(2)Special rules
In pilot testing the continuing care hospital model under paragraph (1), the following rules shall apply:
(A)Such model shall be tested without the limitation to the conditions selected under subsection (a)(2)(B).
(B)Notwithstanding subsection (a)(2)(D), an episode of care shall be defined as the full period that a patient stays in the continuing care hospital plus the first 30 days following discharge from such hospital.
(3)Continuing care hospital defined
In this subsection, the term “continuing care hospital” means an entity that has demonstrated the ability to meet patient care and patient safety standards and that provides under common management the medical and rehabilitation services provided in inpatient rehabilitation hospitals and units (as defined in section 1395ww(d)(1)(B)(ii) of this title), long term care hospitals (as defined in section 1395ww(d)(1)(B)(iv)(I) of this title), and skilled nursing facilities (as defined in section 1395i–3(a) of this title) that are located in a hospital described in section 1395ww(d) of this title.
(h)Administration
Chapter 35 of title 44 shall not apply to the selection, testing, and evaluation of models or the expansion of such models under this section.
Legislative History
Notes & Related Subsidiaries
Editorial Notes
References in Text
Parts A, B, and C, referred to in subsec. (a)(2)(A)(i), are classified to section 1395c et seq., 1395j et seq., and 1395w–21 et seq., respectively, of this title. section 1395ww(d)(1)(B)(iv)(I) of this title, referred to in subsec. (g)(3), was redesignated section 1395ww(d)(1)(B)(iv) of this title by Pub. L. 114–255, div. C, title XV, § 15008(a)(3), Dec. 13, 2016, 130 Stat. 1321. Codification Another section 1866D of act Aug. 14, 1935, was renumbered section 1866E and is classified to section 1395cc–5 of this title.
Amendments
2010—Pub. L. 111–148, § 10308(b)(1), made technical correction to directory language of Pub. L. 111–148, § 3023, which enacted this section. Subsec. (a)(2)(B). Pub. L. 111–148, § 10308(a)(1), substituted “10 conditions” for “8 conditions”. Subsec. (c)(1)(B). Pub. L. 111–148, § 10308(a)(2), added subpar. (B) and struck out former subpar. (B). Prior to amendment, text read as follows: “The Secretary may extend the duration of the pilot program for providers of services and suppliers participating in the pilot program as of the day before the end of the 5-year period described in subparagraph (A), for a period determined appropriate by the Secretary, if the Secretary determines that such extension will result in improving or not reducing the quality of patient care and reducing spending under this subchapter.” Subsec. (g). Pub. L. 111–148, § 10308(a)(3), added subsec. (g) and struck out former subsec. (g). Prior to amendment, text read as follows: “Not later than January 1, 2016, the Secretary shall submit a plan for the implementation of an expansion of the pilot program if the Secretary determines that such expansion will result in improving or not reducing the quality of patient care and reducing spending under this subchapter.”
Reference
Citations & Metadata
Citation
42 U.S.C. § 1395cc–4
Title 42, The Public Health and Welfare
Last Updated
Sep 23, 2026
Release point: 119-110