PUBLIC LAW 109–171—FEB. 8, 2006
120 STAT. 53
(B) technical assistance necessary to support rural PACE pilot sites. (c) COST OUTLIER PROTECTION FOR RURAL PACE PILOT SITES.— (1) ESTABLISHMENT OF FUND FOR REIMBURSEMENT OF OUTLIER COSTS.—Notwithstanding any other provision of law, the Secretary shall establish an outlier fund to reimburse rural PACE pilot sites for recognized outlier costs (as defined in paragraph (3)) incurred for eligible outlier participants (as defined in paragraph (2)) in an amount, subject to paragraph (4), equal to 80 percent of the amount by which the recognized outlier costs exceeds $50,000. (2) ELIGIBLE OUTLIER PARTICIPANT.—For purposes of this subsection, the term ‘‘eligible outlier participant’’ means a PACE program eligible individual (as defined in sections 1894(a)(5) and 1934(a)(5) of the Social Security Act (42 U.S.C. 1395eee(a)(5); 1396u–4(a)(5))) who resides in a rural area and with respect to whom the rural PACE pilot site incurs more than $50,000 in recognized costs in a 12-month period. (3) RECOGNIZED OUTLIER COSTS DEFINED.— (A) IN GENERAL.—For purposes of this subsection, the term ‘‘recognized outlier costs’’ means, with respect to services furnished to an eligible outlier participant by a rural PACE pilot site, the least of the following (as documented by the site to the satisfaction of the Secretary) for the provision of inpatient and related physician and ancillary services for the eligible outlier participant in a given 12month period: (i) If the services are provided under a contract between the pilot site and the provider, the payment rate specified under the contract. (ii) The payment rate established under the original Medicare fee-for-service program for such service. (iii) The amount actually paid for the services by the pilot site. (B) INCLUSION IN ONLY ONE PERIOD.—Recognized outlier costs may not be included in more than one 12month period. (3) OUTLIER EXPENSE PAYMENT.— (A) PAYMENT FOR OUTLIER COSTS.—Subject to subparagraph (B), in the case of a rural PACE pilot site that has incurred outlier costs for an eligible outlier participant, the rural PACE pilot site shall receive an outlier expense payment equal to 80 percent of such costs that exceed $50,000. (4) LIMITATIONS.— (A) COSTS INCURRED PER ELIGIBLE OUTLIER PARTICIPANT.—The total amount of outlier expense payments made under this subsection to a rural PACE pilot site with respect to an eligible outlier participant for any 12-month period shall not exceed $100,000 for the 12-month period used to calculate the payment. (B) COSTS INCURRED PER PROVIDER.—No rural PACE pilot site may receive more than $500,000 in total outlier expense payments in a 12-month period. (C) LIMITATION OF OUTLIER COST REIMBURSEMENT PERIOD.—A rural PACE pilot site shall only receive outlier
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