,,ii  #aac? ,,congress  #a/ ,session    
,s4 #aadc  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,june #ab1 #bjac ,mr4  
,moran 7= himself1 ,mr4 ,?une1 & ,mr4   
,te/]7 introduc$ ! foll[+ bill2 :i* 0   
read twice & ref]r$ to ! ,committee on  
,f9ance  ,a ,,bill  ,to am5d title      
,,xviii ( ! ,social ,security ,act )    
respect to physician sup]vision (       
!rapeutic hospital outpati5t s]vices4   
#a4 ,%ort title ,?is ,act may be cit$ z 
! ,protect+ ,access to ,rural ,!rapy    
,s]vices 7,,p>ts7 ,act4  #b4            
,requirem5ts = physician sup]vision (   
!rapeutic hospital outpati5t s]vices    
7a7 ,!rapeutic hospital outpati5t       
s]vices  7#a7 ,sup]vision requirem5ts   
,section #ahcc ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #aciel7 is am5d$ by 
add+ at ! end ! foll[+ new subsection3  
7z7 ,physician sup]vision requirem5ts = 
!rapeutic hospital outpati5t s]vices    
7#a7 ,g5]al sup]vision = !rapeutic      
s]vices ,except z may be provid$ "u     
p>agraph 7#b71 ins(> z ! ,secret>y      

requires ! sup]vision by a physician or 
a non-physician practition] = paym5t =  
!rapeutic hospital outpati5t s]vices 7z 
def9$ 9 p>agraph 7#e77;,a77 furni%$ "u  
?is "p1 su* requirem5t %all be met if   
su* s]vices are furni%$ "u ! g5]al      
sup]vision 7z def9$ 9 p>agraph          
7#e77;,b77 ( ! physician or             
non-physician practition]1 z ! case may 
be4  7#b7 ,exceptions process =         
high-risk or complex m$ical s]vices     
requir+ a direct level ( sup]vision     
7,a7 ,9 g5]al ,subject to ! succe$+     
provisions ( ?is p>agraph1 ! ,secret>y  
%all e/abli% a process = ! designation (
 !rapeutic hospital outpati5t s]vices   
furni%$ "u ?is "p t1 by reason (        
complexity or high risk1 require--  7i7 
direct sup]vision 7z def9$ 9 p>agraph   
7#e77;,c77 = ! entire s]vice2 or  7ii7  
direct sup]vision dur+ ! initiation ( ! 
s]vice foll[$ by g5]al sup]vision = !   
rema9d] ( ! s]vice4  7,b7 ,consultation 
) cl9ical exp]ts  7i7 ,9 g5]al ,"u !    
process e/abli%$ "u subp>agraph 7,a71   

be=e ! designation ( any !rapeutic      
hospital outpati5t s]vice = :i* direct  
sup]vision may be requir$ "u ?is "p1 !  
,secret>y %all consult ) a panel (      
outside exp]ts describ$ 9 clause 7ii7 to
 advise ! ,secret>y ) respect to ea* su*
 designation4  7ii7 ,advisory panel on  
sup]vision ( !rapeutic hospital         
outpati5t s]vices ,= purposes ( clause  
7i71 a panel ( outside exp]ts describ$ 9
 ?is clause is a panel appo9t$ by !     
,secret>y1 bas$ on nom9ations submitt$  
by hospital1 rural heal?1 & m$ical      
organizations repres5t+ physicians1     
non-physician practition]s1 & hospital  
adm9i/rators1 z ! case may be1 t meets !
 foll[+ requirem5ts3  7,i7 ,composition 
,! panel %all be compos$ ( at lea/ #ae  
physicians & non-physician practition]s 
:o furni% !rapeutic hospital outpati5t  
s]vices = :i* paym5t is made "u ?is "p &
 :o collectively repres5t ! m$ical      
specialties t furni% su* s]vices1 & ( #d
 hospital adm9i/rators ( hospitals      
locat$ 9 rural areas 7z def9$ 9 section 

#ahhf7;d77#b77;,d77 or critical access  
hospitals4  7,,ii7 ,practical exp]i5ce  
requir$ = physicians & non-physician    
practition]s ,dur+ ! #ab-mon? p]iod     
prec$+ appo9tm5t to ! panel by !        
,secret>y1 ea* physician or             
non-physician practition] describ$ 9    
subclause 7,i7 %all h furni%$ !rapeutic 
hospital outpati5t s]vices = :i* paym5t 
0 made "u ?is "p4  7,,iii7 ,m9imum rural
 repres5tation requirem5t = physicians &
 non-physician practition]s ,n less ?an 
#ej p]c5t ( ! memb]%ip ( ! panel t is   
compris$ ( physicians & non-physician   
practition]s %all be physicians or      
non-physician practition]s describ$ 9   
subclause 7,i7 :o practice 9 rural areas
 7z def9$ 9 section #ahhf7;d77#b77;,d77 
or :o furni% su* s]vices 9 critical     
access hospitals4  7iii7 ,application ( 
,,faca ,! ,f$]al ,advisory ,committee   
,act 7#e ,u4,s4,c4 #b ,app471 o!r ?an   
section #ad ( su* ,act1 %all apply to ! 
panel ( outside exp]ts appo9t$ by !     
,secret>y "u clause 7ii74  7,c7 ,special

 rule = outpati5t critical access       
hospital s]vices ,ins(> z a !rapeutic   
outpati5t hospital s]vice t is an       
outpati5t critical access hospital      
s]vice is designat$ z requir+ direct    
sup]vision "u ! process e/abli%$ "u     
subp>agraph 7,a71 ! ,secret>y %all deem 
! critical access hospital furni%+ t    
s]vice z hav+ met ! requirem5t = direct 
sup]vision = t s]vice if1 :5 furni%+ su*
 s]vice1 ! critical access hospital     
meets ! /&>d = p]sonnel requir$ z a     
condition ( p>ticipation "u section     
#dhe4fah7;d7 ( title #db1 ,code ( ,f$]al
 ,regulations 7z 9 effect on ! date ( ! 
enactm5t ( ?is subsection74  7,d7       
,consid]ation ( compliance burd5s ,"u ! 
process e/abli%$ "u subp>agraph 7,a71 ! 
,secret>y %all take into acc\nt ! impact
 on hospitals & critical access         
hospitals 9 comply+ ) requirem5ts =     
direct sup]vision 9 ! furni%+ (         
!rapeutic hospital outpati5t s]vices1   
includ+ hospital res\rces1 availability 
( hospital-privileg$ physicians1        

specialty physicians1 & non-physician   
practition]s1 & adm9i/rative burd5s4    
7,e7 ,requirem5t = notice & comm5t      
rulemak+ ,"u ! process e/abli%$ "u      
subp>agraph 7,a71 ! ,secret>y %all only 
designate !rapeutic hospital outpati5t  
s]vices requir+ direct sup]vision "u ?is
 "p ?r\gh propos$ & f9al rulemak+ t     
provides = public notice & opportunity =
 comm5t4  7,f7 ,rule ( con/ruction ,no?+
 9 ?is subsection %all be con/ru$ z     
au?oriz+ ! ,secret>y to apply or require
 any level ( sup]vision o!r ?an g5]al or
 direct sup]vision ) respect to !       
furni%+ ( !rapeutic hospital outpati5t  
s]vices4  7#c7 ,initial li/ ( designat$ 
s]vices ,! ,secret>y %all include 9 !   
propos$ & f9al regulation = paym5t =    
hospital outpati5t s]vices = #bjae "u   
?is "p a li/ ( initial !rapeutic        
hospital outpati5t s]vices1 if any1     
designat$ "u ! process e/abli%$ "u      
p>agraph 7#b77;,a7 z requir+ direct     
sup]vision "u ?is "p4  7#d7 ,direct     
sup]vision by non-physician practition]s

 = c]ta9 hospital outpati5t s]vices     
p]mitt$  7,a7 ,9 g5]al ,subject to !    
succe$+ provisions ( ?is subsection1 a  
non-physician practition] may directly  
sup]vise ! furni%+ (--  7i7 !rapeutic   
hospital outpati5t s]vices "u ?is "p1   
includ+ c>diac rehabilitation s]vices   
7"u section #ahfa7;eee77#a771 int5sive  
c>diac rehabilitation s]vices 7"u       
section #ahfa7;eee77#d771 & pulmon>y    
rehabilitation s]vices 7"u section      
#ahfa7;fff77#a772 &  7ii7 ^? hospital   
outpati5t diagno/ic s]vices 7describ$ 9 
section #ahfa7s77#b77;,c77 t require    
direct sup]vision "u ! fee s*$ule       
e/abli%$ "u section #ahdh4  7,b7        
,requirem5ts ,subp>agraph 7,a7 %all     
apply ins(> z ! non-physician           
practition] involv$ meets ! foll[+      
requirem5ts3  7i7 ,scope ( practice ,!  
non-physician practition] is act+ )9 !  
scope ( practice "u ,/ate law applicable
 to ! practition]4  7ii7 ,additional    
requirem5ts ,! non-physician practition]
 meets su* requirem5ts z ! ,secret>y may

 specify4  7#e7 ,def9itions ,9 ?is      
subsection3  7,a7 ,!rapeutic hospital   
outpati5t s]vices ,! t]m !rapeutic      
hospital outpati5t s]vices means        
hospital s]vices describ$ 9 section     
#ahfa7s77#b77;,b7 furni%$ by a hospital 
or critical access hospital & includes--
  7i7 c>diac rehabilitation s]vices &   
int5sive c>diac rehabilitation s]vices  
7z def9$ 9 p>agraphs 7#a7 & 7#d71       
respectively1 ( section #ahfa7;eee772 & 
7ii7 pulmon>y rehabilitation s]vices 7z 
def9$ 9 section #ahfa7;fff77#a774  7,b7 
,g5]al sup]vision  7i7 ,ov]all direction
 & control ( physician ,subject to      
clause 7ii71 ) respect to ! furni%+ (   
!rapeutic hospital outpati5t s]vices =  
:i* paym5t may be made "u ?is "p1 ! t]m 
g5]al sup]vision means su* s]vices t are
 furni%$ "u ! ov]all direction & control
 ( a physician or non-physician         
practition]1 z ! case may be4  7ii7     
,pres5ce n requir$ ,= purposes ( clause 
7i71 ! pres5ce ( a physician or         
non-physician practition] is n requir$  

dur+ ! p]=mance ( ! proc$ure involv$4   
7,c7 ,direct sup]vision  7i7 ,provision 
( assi/ance & direction ,subject to     
clause 7ii71 ) respect to ! furni%+ (   
!rapeutic hospital outpati5t s]vices =  
:i* paym5t may be made "u ?is "p1 ! t]m 
direct sup]vision means t a physician or
 non-physician practition]1 z ! case may
 be1 is imm$iately available 7includ+ by
 telephone or o!r means7 to furni%      
assi/ance & direction ?r\gh\t ! furni%+ 
( su* s]vices4 ,su* t]m includes1 )     
respect to ! furni%+ ( a !rapeutic      
hospital outpati5t s]vice = :i* paym5t  
may be made "u ?is "p1 direct sup]vision
 dur+ ! initiation ( ! s]vice foll[$ by 
g5]al sup]vision = ! rema9d] ( ! s]vice 
7z describ$ 9 p>agraph 7#b77;,a77ii774  
7ii7 ,pres5ce 9 room n requir$ ,=       
purposes ( clause 7i71 a physician or   
non-physician practition]1 z ! case may 
be1 is n requir$ to be pres5t 9 ! room  
dur+ ! p]=mance ( ! proc$ure involv$ or 
)9 any o!r physical b\nd>y z long z !   
physician or non-physician practition]1 

z ! case may be1 is imm$iately          
available4  7,d7 ,non-physician         
practition] def9$ ,! t]m non-physician  
practition] means an individual :o--    
7i7 is a physician assi/ant1 a nurse    
practition]1 a cl9ical nurse speciali/1 
a cl9ical social work]1 a cl9ical       
psy*ologi/1 a c]tifi$ nurse midwife1 or 
a c]tifi$ regi/]$ nurse ane/heti/1 &    
includes su* o!r practition]s z !       
,secret>y may specify2 &  7ii7 ) respect
 to ! furni%+ ( !rapeutic outpati5t     
hospital s]vices1 meets ! requirem5ts ( 
p>agraph 7#d77;,b74  4  7#b7 ,con=m+    
am5dm5t ,section #ahfa7;eee77#b77;,b7 ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#aciex7eee77#b77;,b77 is am5d$ by ins]t+
 1 & a non-physician practition] 7z     
def9$ 9 section #ahcc7z77#e77;,d77 may  
sup]vise ! furni%+ ( su* items & s]vices
 9 ! hospital aft] 9 ! case ( items &   
s]vices furni%$ "u su* a program 9 a    
hospital1 su* availability %all be      
presum$4  7b7 ,prohibition on           
retroactive en=cem5t ( revis$           

int]pretation  7#a7 ,repeal ( regulatory
 cl>ification ,! re/atem5t &            
cl>ification "u ! f9al rulemak+ *anges  
to ! ,m$ic>e hospital outpati5t         
prospective paym5t sy/em & cal5d> ye>   
#bjji paym5t rates 7publi%$ 9 ! ,f$]al  
,regi/] on ,novemb] #ah1 #bjjh1 #gc ,f$4
 ,reg4 #fhgjb ?r\gh #fhgjd7 ) respect to
 requirem5ts = direct sup]vision by     
physicians = !rapeutic hospital         
outpati5t s]vices 7z def9$ 9 p>agraph   
7#c77 = purposes ( paym5t = su* s]vices 
"u ! ,m$ic>e program %all h no =ce or   
effect 9 law4  7#b7 ,hold h>mless ,a    
hospital or critical access hospital t  
furni%es !rapeutic hospital outpati5t   
s]vices dur+ ! p]iod beg9n+ on ,janu>y  
#a1 #bjja1 & end+ on ! lat] ( ,decemb]  
#ca1 #bjad1 or ! date on :i* ! f9al     
regulation promulgat$ by ! ,secret>y (  
,heal? & ,human ,s]vices to c>ry out ?is
 ,act takes effect1 = :i* a claim =     
paym5t is made "u "p ,b ( title ,,xviii 
( ! ,social ,security ,act %all n be    
subject to any civil or crim9al action  

or p5alty "u ,f$]al law = failure to    
meet sup]vision requirem5ts "u !        
regulation describ$ 9 p>agraph 7#a71 "u 
program manuals1 or o!rwise4  7#c7      
,!rapeutic hospital outpati5t s]vices   
def9$ ,9 ?is subsection1 ! t]m !rapeutic
 hospital outpati5t s]vices means m$ical
 & o!r heal? s]vices furni%$ by a       
hospital or critical access hospital t  
are--  7,a7 hospital s]vices describ$ 9 
subsection 7s77#b77;,b7 ( section #ahfa 
( ! ,social ,security ,act 7#db         
,u4,s4,c4 #aciex72  7,b7 c>diac         
rehabilitation s]vices or int5sive      
c>diac rehabilitation s]vices 7z def9$ 9
 p>agraphs 7#a7 & 7#d71 respectively1 ( 
subsection 7eee7 ( su* section72 or     
7,c7 pulmon>y rehabilitation s]vices 7z 
def9$ 9 subsection 7fff77#a7 ( su*      
section74