,,ii #aac? ,,congress #b;d ,session ,s4 #bcei ,,9 ,,! ,,s5ate ,,( ,,! ,,unit$ ,,/ates ,may #bj1 #bjad ,mr4 ,frank5 7= himself1 ,mr4 ,rob]ts1 ,mr4 ,h>k91 & ,mr4 ,b>rasso7 introduc$ ! foll[+ bill2 :i* 0 read twice & ref]r$ to ! ,committee on ,f9ance ,a ,,bill ,to am5d title ,,xviii ( ! ,social ,security ,act to protect & pres]ve access ( ,m$ic>e b5efici>ies 9 rural areas to heal? c>e provid]s "u ! ,m$ic>e program1 & = o!r purposes4 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,craig ,?omas ,rural ,hospital & ,provid] ,equity ,act ( #bjad4 7b7 ,table ( ,cont5ts ,! table ( cont5ts ( ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4 ,sec4 #b4 ,s5se ( ! ,s5ate4 ,sec4 #c4 ,fairness 9 ! ,m$ic>e disproportionate %>e hospital 7,,d%7 adju/m5t = rural hospitals4 ,sec4 #d4 ,ext5sion & expansion ( ! ,m$ic>e hold h>mless provision "u ! prospective paym5t sy/em = hospital outpati5t dep>tm5t 7,,hopd7 s]vices = c]ta9 hospitals4 ,sec4 #e4 ,tempor>y improvem5ts to ! ,m$ic>e inpati5t hospital paym5t adju/m5t = l[-volume hospitals4 ,sec4 #f4 ,ext5sion ( ,m$ic>e wage index reclassifications = c]ta9 hospitals4 ,sec4 #g4 ,ext5sion ( ,m$ic>e reasonable co/s paym5ts = c]ta9 cl9ical diagno/ic laboratory te/s furni%$ to hospital pati5ts 9 c]ta9 rural areas4 ,sec4 #h4 ,elim9ation ( isolation te/ = co/-bas$ ambulance reimbursem5t = critical access hospitals4 ,sec4 #i4 ,capital infra/ructure revolv+ loan program4 ,sec4 #aj4 ,ext5sion ( ,m$ic>e inc5tive paym5t program = physician sc>city areas4 ,sec4 #aa4 ,ext5sion ( floor on ,m$ic>e "w geographic adju/m5t4 ,sec4 #ab4 ,recognition ( att5d+ physician assi/ants z att5d+ physicians to s]ve hospice pati5ts4 ,sec4 #ac4 ,improv+ c>e plann+ = ,m$ic>e home heal? s]vices4 ,sec4 #ad4 ,rural heal? cl9ic improvem5ts4 ,sec4 #ae4 ,tempor>y ,m$ic>e paym5t increase = home heal? s]vices furni%$ 9 a rural area4 ,sec4 #af4 ,ext5sion ( increas$ ,m$ic>e paym5ts = rural gr\nd ambulance s]vices4 ,sec4 #ag4 ,cov]age ( m>riage & family !rapi/ s]vices & m5tal heal? c\nselor s]vices "u ,"p ,b ( ! ,m$ic>e program4 ,sec4 #ah4 ,ext5sion ( paym5t = te*nical compon5t ( c]ta9 physician pa?ology s]vices4 ,sec4 #ai4 ,facilitat+ ! provision ( teleheal? s]vices across ,/ate l9es4 ,sec4 #bj4 ,m$ic>e ,"p ,a paym5t = ane/hesiologi/ s]vices 9 c]ta9 rural hospitals bas$ on ,,crna pass-?r\gh rules4 ,sec4 #ba4 ,tempor>y floor on ! practice exp5se geographic index = s]vices furni%$ 9 rural areas outside ( fronti] ,/ates "u ! ,m$ic>e physician fee s*$ule4 ,sec4 #bb4 ,revisions to /&>d = designation ( sole community hospitals4 ,sec4 #bc4 ,m$ic>e treatm5t ( /&by & on-call "t = ,,crna s]vices4 ,sec4 #bd4 ,/ate (fices ( rural heal?4 ,sec4 #be4 ,remov+ ,m$ic>e #if-;h\r physician c]tification requirem5t = inpati5t critical access hospital s]vices4 ,sec4 #bf4 ,ext5sion ( en=cem5t in/ruction on sup]vision requirem5ts = outpati5t !rapeutic s]vices 9 critical access & small rural hospitals ?r\gh #bjad4 #b4 ,s5se ( ! ,s5ate ,x is ! s5se ( ! ,s5ate t-- 7#a7 resid5ts ( rural & fronti] communities %\ld h access to af=dable1 quality heal? c>e2 7#b7 rural & fronti] communities face unique *all5ges 9 heal? c>e deliv]y & f9anc+2 7#c7 ,f$]al heal? policy mu/ reflect ! unique ne$s ( resid5ts ( rural & fronti] communities & su* communities 9 an equitable & su/a9able mann]2 & 7#d7 /akehold]s %\ld "w collectively to id5tify innovative policies t address ! availability1 deliv]y1 & af=dability ( heal? c>e s]vices 9 rural & fronti] communities4 #c4 ,fairness 9 ! ,m$ic>e disproportionate %>e hospital 7,,d%7 adju/m5t = rural hospitals ,section #ahhf7;d77#e77;,f77xiv77,,ii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,f77xiv77,,ii77 is am5d$ by add+ at ! end ! foll[+ new s5t5ce3 ,! prec$+ s5t5ce %all n apply to any hospital ) respect to dis*>ges occurr+ on or aft] ,octob] #a1 #bjad1 & be=e ,octob] #a1 #bjae44 #d4 ,ext5sion & expansion ( ! ,m$ic>e hold h>mless provision "u ! prospective paym5t sy/em = hospital outpati5t dep>tm5t 7,,hopd7 s]vices = c]ta9 hospitals ,section #ahcc7t77#g77;,d77i7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t77#g77;,d77i77 is am5d$-- 7#a7 9 subclause 7,,ii7-- 7,a7 9 ! fir/ s5t5ce1 by ins]t+ & = su* s]vices furni%$ on or aft] ,april #a1 #bjad1 & be=e ,april #a1 #bjae1 aft] cov]$ ,,opd s]vices furni%$ on or aft] ,janu>y #a1 #bjjf1 & be=e ,janu>y #a1 #bjac12 & 7,b7 9 ! second s5t5ce-- 7i7 by /rik+ & #he & ins]t+ #he2 & 7ii7 by ins]t+ ! foll[+ be=e ! p]iod at ! end3 1 & #ajj p]c5t ) respect to su* s]vices furni%$ aft] ,april #a1 #bjad1 & be=e ,april #a1 #bjae2 & 7#b7 9 subclause 7,,iii7-- 7,a7 9 ! fir/ s5t5ce-- 7i7 by ins]t+ & = su* s]vices furni%$ on or aft] ,april #a1 #bjad1 & be=e ,april #a1 #bjae1 aft] cov]$ ,,opd s]vices furni%$ on or aft] ,janu>y #a1 #bjji1 & be=e ,janu>y #a1 #bjac12 & 7ii7 by /rik+ #he p]c5t & ins]t+ ! applicable p]c5tage 7z det]m9$ "u ! second s5t5ce ( subclause 7,,ii7 = ! ye>72 & 7,b7 9 ! second s5t5ce1 by ins]t+ & 9 ! case ( su* s]vices furni%$ on or aft] ,april #a1 #bjad1 & be=e ,april #a1 #bjae1 aft] cov]$ ,,opd s]vices furni%$ on or aft] ,janu>y #a1 #bjaj1 & be=e ,m>* #a1 #bjab14 #e4 ,tempor>y improvem5ts to ! ,m$ic>e inpati5t hospital paym5t adju/m5t = l[-volume hospitals ,section #ahhf7;d77#ab7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#ab77 is am5d$-- 7#a7 9 subp>agraph 7,c77i71 by /rik+ fiscal ye>s #bjaa ?r\gh #bjad & fiscal ye> #bjae 7be=e ,april #a1 #bjae71 #a1fjj dis*>ges ( individuals entitl$ to1 or enroll$ =1 b5efits "u "p ,a & ins]t+ fiscal ye>s #bjaa ?r\gh #bjac & fiscal ye> #bjad 7be=e ,april #a1 #bjad71 #a1fjj dis*>ges ( individuals entitl$ to1 or enroll$ =1 b5efits "u "p ,a1 or1 ) respect to fiscal ye> #bjad 7aft] ,april #a1 #bjad71 fiscal ye> #bjae1 & fiscal ye> #bjaf 7be=e ,janu>y #a1 #bjaf71 #b1jjj dis*>ges ( su* individuals2 & 7#b7 9 subp>agraph 7,d7-- 7,a7 by /rik+ #a1fjj & ins]t+ ! applicable numb] (2 & 7,b7 by add+ at ! end ! foll[+ new s5t5ce3 ,= purposes ( ! prec$+ s5t5ce1 ! t]m applicable numb] ( dis*>ges means #a1fjj dis*>ges ) respect to dis*>ges occurr+ 9 fiscal ye>s #bjaa1 #bjab1 & #bjac1 & fiscal ye> #bjad 7be=e ,april #a1 #bjad71 & #b1jjj dis*>ges ) respect to dis*>ges occurr+ 9 fiscal ye> #bjad 7aft] ,april #a1 #bjad71 fiscal ye> #bjae1 & fiscal ye> #bjaf 7be=e ,janu>y #a1 #bjaf744 #f4 ,ext5sion ( ,m$ic>e wage index reclassifications = c]ta9 hospitals 7a7 ,ext5sion ( correction ( mid-,ye> reclassification expiration = c]ta9 hospitals 7#a7 ,9 g5]al ,9 ! case ( a hospital describ$ 9 p>agraph 7#b71 ! ,secret>y ( ,heal? & ,human ,s]vices %all apply subsection 7a7 ( section #ajf ( division ,b ( ! ,tax ,relief & ,heal? ,c>e ,act ( #bjjf 7#db ,u4,s4,c4 #acieww note71 z am5d$ by section #aag ( ! ,m$ic>e1 ,m$icaid1 & ,,s*ip ,ext5sion ,act ( #bjjg 7,public ,law #aaj-agc71 section #abd ( ! ,m$ic>e ,improvem5ts = ,pati5ts & ,provid]s ,act ( #bjjh 7,public ,law #aaj-bge71 sections #cacg7;a7 & #ajcag ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh71 & section #ajb ( ! ,m$ic>e & ,m$icaid ,ext5d]s ,act ( #bjaj 7,public ,law #aaa-cji71 by sub/itut+ ,april #a1 #bjae = ,m>* #ca1 #bjab4 7#b7 ,hospital describ$ ,a hospital describ$ 9 ?is p>agraph is-- 7,a7 a hospital-- 7i7 t is describ$ 9 subsection 7a7 ( su* section #ajf2 & 7ii7 7,i7 t is locat$ 9 a rural area2 & 7,,ii7 = :i* ! ,secret>y ( ,heal? & ,human ,s]vices has det]m9$ ! ext5sion "u ?is subsection to be appropriate2 or 7,b7 a sole community hospital locat$ 9 a ,/ate ) less ?an #aj p p] squ>e mile t 0 provid$ ) a special exception reclassification ext5sion "u section #aag7;a77#b7 ( ! ,m$ic>e1 ,m$icaid1 & ,,s*ip ,ext5sion ,act ( #bjjg 7,public ,law #aaj-agc74 7b7 ,n budget neutral ,! provisions ( ?is section %all n be effect$ 9 a budget-neutral mann]4 #g4 ,ext5sion ( ,m$ic>e reasonable co/s paym5ts = c]ta9 cl9ical diagno/ic laboratory te/s furni%$ to hospital pati5ts 9 c]ta9 rural areas ,section #daf7;b7 ( ! ,m$ic>e ,prescription ,drug1 ,improvem5t1 & ,mod]nization ,act ( #bjjc 7#db ,u4,s4,c4 #aciel-#d71 z am5d$ by section #aje ( division ,b ( ! ,tax ,relief & ,heal? ,c>e ,act ( #bjjf 7#db ,u4,s4,c4 #aciel note71 section #ajg ( ! ,m$ic>e1 ,m$icaid1 & ,,s*ip ,ext5sion ,act ( #bjjg 7#db ,u4,s4,c4 #aciel note71 section #cabb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh71 & section #aji ( ! ,m$ic>e & ,m$icaid ,ext5d]s ,act ( #bjaj 7,public ,law #aaa-cji71 is am5d$ by ins]t+ 1 ! portion ( fiscal ye> #bjad aft] ,april #a1 #bjad1 or ! portion ( fiscal ye> #bjae be=e ,april #a1 #bjae aft] ! #b-ye> p]iod beg9n+ on ,july #a1 #bjaj4 #h4 ,elim9ation ( isolation te/ = co/-bas$ ambulance reimbursem5t = critical access hospitals 7a7 ,9 g5]al ,section #ahcd7l77#h7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l77#h77 is am5d$-- 7#a7 9 subp>agraph 7,b7-- 7,a7 by /rik+ own$ &2 & 7,b7 by ins]t+ 7includ+ :5 su* s]vices are provid$ by ! entity "u an arrangem5t ) ! hospital7 aft] hospital2 & 7#b7 by /rik+ ! comma at ! end ( subp>agraph 7,b7 & all t foll[s & ins]t+ a p]iod4 7b7 ,effective date ,! am5dm5ts made by ?is section %all apply to s]vices furni%$ on or aft] ,janu>y #a1 #bjae4 #i4 ,capital infra/ructure revolv+ loan program 7a7 ,9 ,g5]al ,"p ,a ( title ,,xvi ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjjq et seq47 is am5d$ by add+ at ! end ! foll[+ new section3 #afjc4 ,capital infra/ructure revolv+ loan program 7a7 ,au?ority ,to ,make & ,gu>antee ,loans 7#a7 ,au?ority to make loans ,! ,secret>y may make loans f ! fund e/abli%$ "u section #afjb7;d7 to any rural entity = projects = capital improvem5ts1 includ+-- 7,a7 ! acquisition ( l& necess>y = ! capital improvem5ts2 7,b7 ! r5ovation or mod]nization ( any build+2 7,c7 ! acquisition or repair ( fix$ or major movable equipm5t2 & 7,d7 su* o!r project exp5ses z ! ,secret>y det]m9es appropriate4 7#b7 ,au?ority to gu>antee loans 7,a7 ,9 g5]al ,! ,secret>y may gu>antee ! paym5t ( pr9cipal & int]e/ = loans made to rural entities = projects = any capital improvem5t describ$ 9 p>agraph 7#a7 to any non-,f$]al l5d]4 7,b7 ,int]e/ subsidies ,9 ! case ( a gu>antee ( any loan made to a rural entity "u subp>agraph 7,a71 ! ,secret>y may pay to ! hold] ( su* loan1 = & on behalf ( ! project = :i* ! loan 0 made1 am\nts suffici5t to r$uce 7by n m ?an #c p]c5t7 ! net effective int]e/ rate o!rwise payable on su* loan4 7b7 ,am\nt ( ,loan ,! pr9cipal am\nt ( a loan directly made or gu>ante$ "u subsection 7a7 = a project = capital improvem5t may n exce$ #e1jjj1jjj4 7c7 ,fund+ ,limitations 7#a7 ,gov]nm5t cr$it subsidy exposure ,! total ( ! ,gov]nm5t cr$it subsidy exposure "u ! ,cr$it ,re=m ,act ( #aiij scor+ protocol ) respect to ! loans out/&+ at any "t ) respect to :i* gu>antees h be5 issu$1 or :i* h be5 directly made1 "u subsection 7a7 may n exce$ #ej1jjj1jjj p] ye>4 7#b7 ,total am\nts ,subject to p>agraph 7#a71 ! total ( ! pr9cipal am\nt ( all loans directly made or gu>ante$ "u subsection 7a7 may n exce$ #bej1jjj1jjj p] ye>4 7d7 ,capital ,assessm5t & ,plann+ ,grants 7#a7 ,nonrepayable grants ,subject to p>agraph 7#b71 ! ,secret>y may make a grant to a rural entity1 9 an am\nt n to exce$ #ej1jjj1 = purposes ( capital assessm5t & bus9ess plann+4 7#b7 ,limitation ,! cumulative total ( grants aw>d$ "u ?is subsection may n exce$ #b1ejj1jjj p] ye>4 7e7 ,t]m9ation ( ,au?ority ,! ,secret>y may n directly make or gu>antee any loan "u subsection 7a7 or make a grant "u subsection 7d7 aft] ,janu>y #a1 #bjae4 4 7b7 ,rural ,entity ,def9$ ,section #afbd ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjjs-#c7 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#ae7 7,a7 ,! t]m rural entity includes-- 7i7 a rural heal? cl9ic1 z def9$ 9 section #ahfa7;aa77#b7 ( ! ,social ,security ,act2 7ii7 any m$ical facility ) at lea/ #a b$1 b ) less ?an #ej b$s1 t is locat$ 9-- 7,i7 a c\nty t is n "p ( a metropolitan /ati/ical area2 or 7,,ii7 a rural c5sus tract ( a metropolitan /ati/ical area 7z det]m9$ "u ! mo/ rec5t modification ( ! ,goldsmi? ,modification1 orig9ally publi%$ 9 ! ,f$]al ,regi/] on ,febru>y #bg1 #aiib 7#eg ,f$4 ,reg4 #fgbe772 7iii7 a hospital t is classifi$ z a rural1 regional1 or national ref]ral c5t] "u section #ahhf7;d77#e77;,c7 ( ! ,social ,security ,act2 & 7iv7 a hospital t is a sole community hospital 7z def9$ 9 section #ahhf7;d77#e77;,d77iii7 ( ! ,social ,security ,act74 7,b7 ,= purposes ( subp>agraph 7,a71 ! fact t a cl9ic1 facility1 or hospital has be5 geographically reclassifi$ "u ! ,m$ic>e program "u title ,,xviii ( ! ,social ,security ,act %all n preclude a hospital f be+ consid]$ a rural entity "u clause 7i7 or 7ii7 ( subp>agraph 7,a74 4 7c7 ,con=m+ ,am5dm5ts ,section #afjb ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjjq-#b7 is am5d$-- 7#a7 9 subsection 7b77#b77;,d71 by ins]t+ or #afjc7;a77#b77;,b7 aft] #afja7;a77#b77;,b72 & 7#b7 9 subsection 7d7-- 7,a7 9 p>agraph 7#a77;,c71 by /rik+ section #afja7;a77#b77;,b7 & ins]t+ sections #afja7;a77#b77;,b7 & #afjc7;a77#b77;,b72 & 7,b7 9 p>agraph 7#b77;,a71 by ins]t+ or #afjc7;a77#b77;,b7 aft] #afja7;a77#b77;,b74 #aj4 ,ext5sion ( ,m$ic>e inc5tive paym5t program = physician sc>city areas ,section #ahcc7u77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7u77#a77 is am5d$ by ins]t+ 1 & su* s]vices furni%$ on or aft] ,april #a1 #bjad1 & be=e ,april #a1 #bjae aft] #bjjh4 #aa4 ,ext5sion ( floor on ,m$ic>e "w geographic adju/m5t ,section #ahdh7;e77#a77;,e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;e77#a77;,e77 is am5d$ by /rik+ ,april #a1 #bjae & ins]t+ ,janu>y #a1 #bjaf4 #ab4 ,recognition ( att5d+ physician assi/ants z att5d+ physicians to s]ve hospice pati5ts 7a7 ,9 ,g5]al ,section #ahfa7;dd77#c77;,b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7dd77#c77;,b77 is am5d$-- 7#a7 by /rik+ or nurse practition] & ins]t+ 1 ! nurse practition]2 & 7#b7 by ins]t+ 1 or ! physician assi/ant 7z def9$ 9 su* subsection7 aft] subsection 7aa77#e774 7b7 ,p]mitt+ physician assi/ants :5 delegat$ by a physician ,to ord] hospice c>e ,section #ahad7;a77#g77;,a7 ( su* ,act 7#db ,u4,s4,c4 #acie;f7a77#g77;,a77 is am5d$-- 7#a7 9 clause 7i77,i71 by /rik+ does n include a nurse practition] & ins]t+ only includes a physician assi/ant if a physician has delegat$ ! au?ority to make ! c]tification requir$ "u ?is p>agraph to su* physician assi/ant2 & 7#b7 by am5d+ clause 7ii7 to read z foll[s3 7ii7 9 a subsequ5t #ij- or #fj-;day p]iod-- 7,i7 ! m$ical director or physician describ$ 9 clause 7i77,,ii72 7,,ii7 a physician employ$ by ! hospice program provid+ 7or arrang+ =7 ! c>e or provid+ c>e to ! individual "u arrangem5t ) su* hospice program2 7,,iii7 a nurse practition] employ$ by su* hospice program or provid+ c>e to ! individual "u arrangem5t ) su* hospice program2 or 7,,iv7 a physician assi/ant employ$ by su* hospice program or provid+ c>e to ! individual "u arrangem5t ) su* hospice program1 provid$ t an individual describ$ 9 subclause 7,i7 or 7,,ii7 has delegat$ ! au?ority to make ! rec]tification requir$ "u ?is clause to su* physician assi/ant1 rec]tifies at ! beg9n+ ( ! p]iod t ! individual is t]m9ally ill bas$ on su* cl9ical judgm5t2 4 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply to items & s]vices furni%$ on or aft] ,janu>y #a1 #bjae4 #ac4 ,improv+ c>e plann+ = ,m$ic>e home heal? s]vices 7a7 ,"p ,a provisions ,section #ahad7;a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7a77 is am5d$-- 7#a7 9 p>agraph 7#b7-- 7,a7 9 ! matt] prec$+ subp>agraph 7,a71 by ins]t+ 1 a nurse practition] or cl9ical nurse speciali/ :o is work+ 9 collaboration ) a physician 9 accordance ) ,/ate law1 a c]tifi$ nurse-midwife 7z def9$ 9 section #ahfa7;gg77 z au?oriz$ by ,/ate law1 or a physician assi/ant 7z def9$ 9 section #ahfa7;aa77#e77 "u ! sup]vision ( a physician aft] #ahff7;j72 & 7,b7 9 subp>agraph 7,c7-- 7i7 by ins]t+ 1 a nurse practition]1 a cl9ical nurse speciali/1 a c]tifi$ nurse-midwife1 or a physician assi/ant 7z ! case may be7 aft] physician ! fir/ #b times x appe>s2 & 7ii7 by /rik+ 1 &1 9 ! case ( a c]tification made by a physician & all t foll[s ?r\gh face-to-face enc\nt] & ins]t+ 1 &1 9 ! case ( a c]tification made by a physician aft] ,janu>y #a1 #bjaj1 or by a nurse practition]1 cl9ical nurse speciali/1 c]tifi$ nurse-midwife1 or physician assi/ant 7z ! case may be7 aft] ,janu>y #a1 #bjae1 prior to mak+ su* c]tification ! physician1 nurse practition]1 cl9ical nurse speciali/1 c]tifi$ nurse-midwife1 or physician assi/ant mu/ docum5t t ! physician1 nurse practition]1 cl9ical nurse speciali/1 c]tifi$ nurse-midwife1 or physician assi/ant has _h a face-to-face enc\nt]2 & 7#b7 9 ! flu% matt] foll[+ p>agraph 7#h7-- 7,a7 9 ! fir/ s5t5ce1 by ins]t+ c]tifi$ nurse-midwife1 aft] cl9ical nurse speciali/12 7,b7 9 ! second s5t5ce-- 7i7 by /rik+ physician c]tification & ins]t+ c]tification2 7ii7 by ins]t+ 7or on ,janu>y #a1 #bjae1 9 ! case ( regulations to implem5t ! am5dm5ts made by section #ac ( ! ,craig ,?omas ,rural ,hospital & ,provid] ,equity ,act ( #bjad7 aft] #aiha2 & 7iii7 by /rik+ a physician :o & ins]t+ a physician1 nurse practition]1 cl9ical nurse speciali/1 c]tifi$ nurse-midwife1 or physician assi/ant :o2 & 7,c7 9 ! ?ird s5t5ce1 by ins]t+ 1 nurse practition]1 cl9ical nurse speciali/1 c]tifi$ nurse-midwife1 or physician assi/ant aft] physician4 7b7 ,"p ,b provisions ,section #ahce7;a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acien7a77 is am5d$-- 7#a7 9 p>agraph 7#b7-- 7,a7 9 ! matt] prec$+ subp>agraph 7,a71 by ins]t+ 1 a nurse practition] or cl9ical nurse speciali/ 7z ^? t]ms are def9$ 9 section #ahfa7;aa77#e77 :o is work+ 9 collaboration ) a physician 9 accordance ) ,/ate law1 a c]tifi$ nurse-midwife 7z def9$ 9 section #ahfa7;gg77 z au?oriz$ by ,/ate law1 or a physician assi/ant 7z def9$ 9 section #ahfa7;aa77#e77 "u ! sup]vision ( a physician aft] #ahff7;j72 & 7,b7 9 subp>agraph 7,a7-- 7i7 9 ea* ( clauses 7ii7 & 7iii7 ( subp>agraph 7,a7 by ins]t+ 1 a nurse practition]1 a cl9ical nurse speciali/1 a c]tifi$ nurse-midwife1 or a physician assi/ant 7z ! case may be7 aft] physician2 & 7ii7 9 clause 7iv71 by /rik+ aft] ,janu>y #a1 #bjaj & all t foll[s ?r\gh face-to-face enc\nt] & ins]t+ made by a physician aft] ,janu>y #a1 #bjaj1 or by a nurse practition]1 cl9ical nurse speciali/1 c]tifi$ nurse-midwife1 or physician assi/ant 7z ! case may be7 aft] ,janu>y #a1 #bjae1 prior to mak+ su* c]tification ! physician1 nurse practition]1 cl9ical nurse speciali/1 c]tifi$ nurse-midwife1 or physician assi/ant mu/ docum5t t ! physician1 nurse practition]1 cl9ical nurse speciali/1 c]tifi$ nurse-midwife1 or physician assi/ant has _h a face-to-face enc\nt]2 7#b7 9 ! ?ird s5t5ce1 by ins]t+ 1 nurse practition]1 cl9ical nurse speciali/1 c]tifi$ nurse-midwife1 or physician assi/ant 7z ! case may be7 aft] physician2 7#c7 9 ! f\r? s5t5ce-- 7,a7 by /rik+ physician c]tification & ins]t+ c]tification2 7,b7 by ins]t+ 7or on ,janu>y #a1 #bjae1 9 ! case ( regulations to implem5t ! am5dm5ts made by section #ac ( ! ,craig ,?omas ,rural ,hospital & ,provid] ,equity ,act ( #bjad7 aft] #aiha2 & 7,c7 by /rik+ a physician :o & ins]t+ a physician1 nurse practition]1 cl9ical nurse speciali/1 c]tifi$ nurse-midwife1 or physician assi/ant :o2 & 7#d7 9 ! fif? s5t5ce1 by ins]t+ 1 nurse practition]1 cl9ical nurse speciali/1 c]tifi$ nurse-midwife1 or physician assi/ant aft] physician4 7c7 ,def9ition provisions 7#a7 ,home heal? s]vices ,section #ahfa7m7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7m77 is am5d$-- 7,a7 9 ! matt] prec$+ p>agraph 7#a7-- 7i7 by ins]t+ 1 a nurse practition] or a cl9ical nurse speciali/ 7z ^? t]ms are def9$ 9 subsection 7aa77#e771 a c]tifi$ nurse-midwife 7z def9$ 9 section #ahfa7;gg771 or a physician assi/ant 7z def9$ 9 subsection 7aa77#e77 aft] physician ! fir/ place x appe>s2 & 7ii7 by ins]t+ 1 a nurse practition]1 a cl9ical nurse speciali/1 a c]tifi$ nurse-midwife1 or a physician assi/ant aft] physician ! second place x appe>s2 & 7,b7 9 p>agraph 7#c71 by ins]t+ 1 a nurse practition]1 a cl9ical nurse speciali/1 a c]tifi$ nurse-midwife1 or a physician assi/ant aft] physician4 7#b7 ,home heal? ag5cy ,section #ahfa7o77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7o77#b77 is am5d$-- 7,a7 by ins]t+ 1 nurse practition]s or cl9ical nurse speciali/s 7z ^? t]ms are def9$ 9 subsection 7aa77#e771 c]tifi$ nurse-midwives 7z def9$ 9 section #ahfa7;gg771 or physician assi/ants 7z def9$ 9 subsection 7aa77#e77 aft] physicians2 & 7,b7 by ins]t+ 1 nurse practition]1 cl9ical nurse speciali/1 c]tifi$ nurse-midwife1 physician assi/ant1 aft] physician4 7d7 ,home heal? prospective paym5t sy/em provisions ,section #ahie ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;fff7 is am5d$-- 7#a7 9 subsection 7c77#a71 by ins]t+ 1 ! nurse practition] or cl9ical nurse speciali/ 7z ^? t]ms are def9$ 9 section #ahfa7;aa77#e771 ! c]tifi$ nurse-midwife 7z def9$ 9 section #ahfa7;gg771 or ! physician assi/ant 7z def9$ 9 section #ahfa7;aa77#e771 aft] physician2 & 7#b7 9 subsection 7e7-- 7,a7 9 p>agraph 7#a77;,a71 by ins]t+ 1 a nurse practition] or cl9ical nurse speciali/ 7z ^? t]ms are def9$ 9 section #ahfa7;aa77#e771 a c]tifi$ nurse-midwife 7z def9$ 9 section #ahfa7;gg771 or a physician assi/ant 7z def9$ 9 section #ahfa7;aa77#e77 aft] physician2 & 7,b7 9 p>agraph 7#b7-- 7i7 9 ! head+1 by /rik+ ,physician c]tification & ins]t+ ,rule ( con/ruction reg>d+ requirem5t = c]tification2 & 7ii7 by /rik+ physician4 7e7 ,effective ,date ,! am5dm5ts made by ?is section %all apply to items & s]vices furni%$ on or aft] ,janu>y #a1 #bjae4 #ad4 ,rural heal? cl9ic improvem5ts ,section #ahcc7;f7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7f77 is am5d$-- 7#a7 9 p>agraph 7#a71 by /rik+ 1 & at ! end & ins]t+ a semicolon2 7#b7 9 p>agraph 7#b7-- 7,a7 by ins]t+ 7be=e #bjae7 aft] 9 a subsequ5t ye>2 & 7,b7 by /rik+ ! p]iod at ! end & ins]t+ a semicolon2 & 7#c7 by add+ at ! end ! foll[+ new p>agraphs3 7#c7 9 #bjae1 at #aja p] visit2 & 7#d7 = ye>s foll[+ #bjae1 at ! limit e/abli%$ "u ?is subsection = ! previ\s ye> increas$ by ! p]c5tage increase 9 ! ,,mei 7z s def9$7 applicable to prim>y c>e s]vices 7z s def9$7 furni%$ z ( ! fir/ day ( t ye>4 4 #ae4 ,tempor>y ,m$ic>e paym5t increase = home heal? s]vices furni%$ 9 a rural area ,section #dba7;a7 ( ! ,m$ic>e ,prescription ,drug1 ,improvem5t1 & ,mod]nization ,act ( #bjjc 7,public ,law #ajh-agc2 #aag ,/at4 #bbhc71 z am5d$ by section #ebja7;b7 ( ! ,deficit ,r$uction ,act ( #bjje 7,public ,law #aji-aga2 #abj ,/at4 #df7 & section #caca7;c7 ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh2 #abd ,/at4 #dbh71 is am5d$ by /rik+ ,janu>y #a1 #bjaf1 #c p]c5t & ins]t+ ,april #a1 #bjad1 & episodes & visits end+ on or aft] ,april #a1 #bjae1 & be=e ,janu>y #a1 #bjaf1 #c p]c5t4 #af4 ,ext5sion ( increas$ ,m$ic>e paym5ts = rural gr\nd ambulance s]vices 7a7 ,9 g5]al ,section #ahcd7l77#ac77;,a77i7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l77#ac77;,a77i77 is am5d$ by /rik+ be=e ,april #a1 #bjae & ins]t+ be=e ,april #a1 #bjad1 or #e p]c5t if su* s]vice is furni%$ on or aft] ,april #a1 #bjad1 & be=e ,janu>y #a1 #bjaf4 7b7 ,sup] rural ambulance ,section #ahcd7l77#ab77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l77#ab77;,a77 is am5d$ by /rik+ ,april #a1 #bjae & ins]t+ ,janu>y #a1 #bjaf4 #ag4 ,cov]age ( m>riage & family !rapi/ s]vices & m5tal heal? c\nselor s]vices "u ,"p ,b ( ! ,m$ic>e program 7a7 ,cov]age ( ,s]vices 7#a7 ,9 g5]al ,section #ahfa7s77#b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7s77#b77 is am5d$-- 7,a7 9 subp>agraph 7,,ee71 by /rik+ & aft] ! semicolon at ! end2 7,b7 9 subp>agraph 7,,ff71 by ins]t+ & aft] ! semicolon at ! end2 & 7,c7 by add+ at ! end ! foll[+ new subp>agraph3 7,,gg7 m>riage & family !rapi/ s]vices 7z def9$ 9 subsection 7iii77#a77 & m5tal heal? c\nselor s]vices 7z def9$ 9 subsection 7iii77#c772 4 7#b7 ,def9itions ,section #ahfa ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7iii7 ,m>riage & ,family ,!rapi/ ,s]vices2 ,m>riage & ,family ,!rapi/2 ,m5tal ,heal? ,c\nselor ,s]vices2 ,m5tal ,heal? ,c\nselor 7#a7 ,! t]m m>riage & family !rapi/ s]vices means s]vices p]=m$ by a m>riage & family !rapi/ 7z def9$ 9 p>agraph 7#b77 = ! diagnosis & treatm5t ( m5tal illnesses1 :i* ! m>riage & family !rapi/ is legally au?oriz$ to p]=m "u ,/ate law 7or ! ,/ate regulatory me*anism provid$ by ,/ate law7 ( ! ,/ate 9 :i* su* s]vices are p]=m$1 z w\ld o!rwise be cov]$ if furni%$ by a physician or z an incid5t to a physician's pr(essional s]vice1 b only if no facility or o!r provid] *>ges or is paid any am\nts ) respect to ! furni%+ ( su* s]vices4 7#b7 ,! t]m m>riage & family !rapi/ means an individual :o-- 7,a7 possesses a ma/]'s or doctoral degree :i* qualifies = lic5sure or c]tification z a m>riage & family !rapi/ pursuant to ,/ate law2 7,b7 aft] obta9+ su* degree has p]=m$ at lea/ #b ye>s ( cl9ical sup]vis$ exp]i5ce 9 m>riage & family !rapy2 & 7,c7 9 ! case ( an individual p]=m+ s]vices 9 a ,/ate t provides = lic5sure or c]tification ( m>riage & family !rapi/s1 is lic5s$ or c]tifi$ z a m>riage & family !rapi/ 9 su* ,/ate4 7#c7 ,! t]m m5tal heal? c\nselor s]vices means s]vices p]=m$ by a m5tal heal? c\nselor 7z def9$ 9 p>agraph 7#d77 = ! diagnosis & treatm5t ( m5tal illnesses :i* ! m5tal heal? c\nselor is legally au?oriz$ to p]=m "u ,/ate law 7or ! ,/ate regulatory me*anism provid$ by ! ,/ate law7 ( ! ,/ate 9 :i* su* s]vices are p]=m$1 z w\ld o!rwise be cov]$ if furni%$ by a physician or z incid5t to a physician's pr(essional s]vice1 b only if no facility or o!r provid] *>ges or is paid any am\nts ) respect to ! furni%+ ( su* s]vices4 7#d7 ,! t]m m5tal heal? c\nselor means an individual :o-- 7,a7 possesses a ma/]'s or doctor's degree 9 m5tal heal? c\nsel+ or a relat$ field2 7,b7 aft] obta9+ su* a degree has p]=m$ at lea/ #b ye>s ( sup]vis$ m5tal heal? c\nselor practice2 & 7,c7 9 ! case ( an individual p]=m+ s]vices 9 a ,/ate t provides = lic5sure or c]tification ( m5tal heal? c\nselors or pr(essional c\nselors1 is lic5s$ or c]tifi$ z a m5tal heal? c\nselor or pr(essional c\nselor 9 su* ,/ate4 4 7#c7 ,provision = paym5t "u "p ,b ,section #ahcb7;a77#b77;,b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciek7a77#b77;,b77 is am5d$ by add+ at ! end ! foll[+ new clause3 7v7 m>riage & family !rapi/ s]vices 7z def9$ 9 section #ahfa7;iii77#a77 & m5tal heal? c\nselor s]vices 7z def9$ 9 section #ahfa7;iii77#c772 4 7#d7 ,am\nt ( paym5t ,section #ahcc7;a77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7a77#a77 is am5d$-- 7,a7 by /rik+ & 7,z7 & ins]t+ 7,z72 & 7,b7 by ins]t+ be=e ! semicolon at ! end ! foll[+3 1 & 7,,aa7 ) respect to m>riage & family !rapi/ s]vices & m5tal heal? c\nselor s]vices "u section #ahfa7s77#b77;,,gg71 ! am\nts paid %all be #hj p]c5t ( ! less] ( ! actual *>ge = ! s]vices or #ge p]c5t ( ! am\nt det]m9$ = paym5t ( a psy*ologi/ "u subp>agraph 7,l74 7#e7 ,exclusion ( m>riage & family !rapi/ s]vices & m5tal heal? c\nselor s]vices f skill$ nurs+ facility prospective paym5t sy/em ,section #ahhh7;e77#b77;,a77ii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieyy7e77#b77;,a77ii77 is am5d$ by ins]t+ m>riage & family !rapi/ s]vices 7z def9$ 9 section #ahfa7;iii77#a771 m5tal heal? c\nselor s]vices 7z def9$ 9 section #ahfa7;iii77#c771 aft] qualifi$ psy*ologi/ s]vices14 7#f7 ,inclusion ( m>riage & family !rapi/s & m5tal heal? c\nselors z practition]s = assignm5t ( claims ,section #ahdb7;b77#ah77;,c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieu7b77#ah77;,c77 is am5d$ by add+ at ! end ! foll[+ new clauses3 7vii7 ,a m>riage & family !rapi/ 7z def9$ 9 section #ahfa7;iii77#b774 7viii7 ,a m5tal heal? c\nselor 7z def9$ 9 section #ahfa7;iii77#d774 4 7b7 ,cov]age ( ,c]ta9 ,m5tal ,heal? ,s]vices ,provid$ 9 ,c]ta9 ,sett+s 7#a7 ,rural heal? cl9ics & f$]ally qualifi$ heal? c5t]s ,section #ahfa7;aa77#a77;,b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7aa77#a77;,b77 is am5d$ by /rik+ or by a cl9ical social work] 7z def9$ 9 subsection 7hh77#a77 & ins]t+ 1 by a cl9ical social work] 7z def9$ 9 subsection 7hh77#a771 by a m>riage & family !rapi/ 7z def9$ 9 subsection 7iii77#b771 or by a m5tal heal? c\nselor 7z def9$ 9 subsection 7iii77#d774 7#b7 ,hospice programs ,section #ahfa7;dd77#b77;,b77i77,,iii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7dd77#b77;,b77i77,,iii77 is am5d$ by ins]t+ 1 m>riage & family !rapi/1 or m5tal heal? c\nselor aft] social work]4 7c7 ,au?orization ( m>riage & family !rapi/s & m5tal heal? c\nselors ,to develop dis*>ge plans = po/-,hospital s]vices ,section #ahfa7;ee77#b77;,g7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex7ee77#b77;,g77 is am5d$ by ins]t+ 1 includ+ a m>riage & family !rapi/ & a m5tal heal? c\nselor :o meets qualification /&>ds e/abli%$ by ! ,secret>y be=e ! p]iod at ! end4 7d7 ,effective ,date ,! am5dm5ts made by ?is section %all apply ) respect to s]vices furni%$ on or aft] ,janu>y #a1 #bjae4 #ah4 ,ext5sion ( paym5t = te*nical compon5t ( c]ta9 physician pa?ology s]vices ,section #edb7;c7 ( ! ,m$ic>e1 ,m$icaid1 & ,,s*ip ,b5efits ,improvem5t & ,protection ,act ( #bjjj 7z enact$ into law by section #a7;a77#f7 ( ,public ,law #ajf-eed71 z am5d$ by section #gcb ( ! ,m$ic>e ,prescription ,drug1 ,improvem5t1 & ,mod]nization ,act ( #bjjc 7#db ,u4,s4,c4 #aciew-#d note71 section #ajd ( division ,b ( ! ,tax ,relief & ,heal? ,c>e ,act ( #bjjf 7#db ,u4,s4,c4 #aciew-#d note71 section #ajd ( ! ,m$ic>e1 ,m$icaid1 & ,,s*ip ,ext5sion ,act ( #bjjg 7,public ,law #aaj-agc71 section #acf ( ! ,m$ic>e ,improvem5ts = ,pati5ts & ,provid]s ,act ( #bjjh 7,public ,law #aaj-bge71 section #cajd ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh71 & section #aje ( ! ,m$ic>e & ,m$icaid ,ext5d]s ,act ( #bjaj 7,public ,law #aaa-cji71 is am5d$ by /rik+ #bjaj1 & #bjaa & ins]t+ #bjaj1 #bjaa1 ! portion ( fiscal ye> #bjad aft] ,april #a1 #bjad1 & ! portion ( fiscal ye> #bjae be=e ,april #a1 #bjae4 #ai4 ,facilitat+ ! provision ( teleheal? s]vices across ,/ate l9es 7a7 ,9 g5]al ,= purposes ( exp$it+ ! provision ( teleheal? s]vices1 = :i* paym5t is made "u ! ,m$ic>e program1 across ,/ate l9es1 ! ,secret>y ( ,heal? & ,human ,s]vices %all1 9 consultation ) repres5tatives ( ,/ates1 physicians1 heal? c>e practition]s1 & pati5t advocates1 enc\rage & facilitate ! adoption ( provisions all[+ = multi/ate practition] practice across ,/ate l9es4 7b7 ,def9itions ,9 subsection 7a73 7#a7 ,teleheal? s]vice ,! t]m teleheal? s]vice has ! mean+ giv5 t t]m 9 subp>agraph 7,f7 ( section #ahcd7m77#d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem7m77#d774 7#b7 ,physician1 practition] ,! t]ms physician & practition] h ! mean+ giv5 ^? t]ms 9 subp>agraphs 7,d7 & 7,e71 respectively1 ( su* section4 7#c7 ,m$ic>e program ,! t]m ,m$ic>e program means ! program ( heal? insurance adm9i/]$ by ! ,secret>y ( ,heal? & ,human ,s]vices "u title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq474 #bj4 ,m$ic>e ,"p ,a paym5t = ane/hesiologi/ s]vices 9 c]ta9 rural hospitals bas$ on ,,crna pass-?r\gh rules 7a7 ,9 g5]al ,section #ahad ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7m7 ,ane/hesiologi/ s]vices provid$ 9 c]ta9 rural hospitals 7#a7 ,not)/&+ any o!r provision ( ?is title1 cov]age & paym5t %all be provid$ "u ?is "p = physicians' s]vices t are ane/hesia s]vices furni%$ by a physician :o is an ane/hesiologi/ 9 a rural hospital describ$ 9 p>agraph 7#c7 9 ! same mann] z paym5t is made "u ! exception provid$ 9 section #icbj7k7 ( ! ,omnibus ,budget ,reconciliation ,act ( #aihf1 z add$ by section #fjh7;c77#b7 ( ! ,family ,support ,act ( #aihh & am5d$ by section #facb ( ! ,omnibus ,budget ,reconciliation ,act ( #aihi1 7relat+ to paym5t on a reasonable co/1 pass-?r\gh basis7 = c]tifi$ regi/]$ nurse ane/heti/ s]vices furni%$ by a c]tifi$ regi/]$ nurse ane/heti/ 9 a hospital describ$ 9 su* section #icbj7k74 7#b7 ,no paym5t %all be made "u any o!r provision ( ?is title = physicians' s]vices = :i* paym5t is made "u ?is subsection4 7#c7 ,a rural hospital describ$ 9 ?is p>agraph is a hospital describ$ 9 section #icbj7k7 ( ! ,omnibus ,budget ,reconciliation ,act ( #aihf1 z s add$ & am5d$1 except t-- 7,a7 any ref]5ce 9 su* section to a c]tifi$ regi/]$ nurse ane/heti/ or an ane/heti/ is deem$ a ref]5ce to a physician :o is an ane/hesiologi/ or an ane/hesiologi/1 respectively2 & 7,b7 any ref]5ce to ,janu>y #a1 #aihh or #aihg is deem$ a ref]5ce to su* date & ye> z ! ,secret>y %all specify4 4 7b7 ,effective date ,! am5dm5t made by subsection 7a7 %all apply to s]vices furni%$ dur+ co/ report+ p]iods beg9n+ on or aft] ! date ( ! enactm5t ( ?is ,act4 #ba4 ,tempor>y floor on ! practice exp5se geographic index = s]vices furni%$ 9 rural areas outside ( fronti] ,/ates "u ! ,m$ic>e physician fee s*$ule ,section #ahdh7;e77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;e77#a77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,j7 ,floor at #a4j on practice exp5se geographic index = s]vices furni%$ 9 rural areas outside ( fronti] ,/ates ,= purposes ( paym5t = s]vices furni%$ 9 a rural area 7o!r ?an a rural area locat$ 9 a ,/ate to :i* subp>agraph 7,i7 applies7 on or aft] ,april #a1 #bjad1 & be=e ,april #a1 #bjae1 aft] calculat+ ! practice exp5se index "u subp>agraph 7,a77i71 ! ,secret>y %all increase any su* index to #a4j if su* index w\ld o!rwise be less ?an #a4j4 ,! prec$+ s5t5ce %all n be appli$ 9 a budget neutral mann]4 4 #bb4 ,revisions to /&>d = designation ( sole community hospitals ,section #ahhf7;d77#e77;,d77iv7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,d77iv77 is am5d$ by add+ at ! end ! foll[+ new s5t5ce3 ,"u su* /&>d1 ! "t requir$ = an individual to travel to ! ne>e/ alt]native s\rce ( c>e %all be measur$ ov] improv$ roads ma9ta9$ by a local1 ,/ate1 or ,f$]al ,gov]nm5t entity = use by ! g5]al public :i* is ! mo/ exp$iti\s & accessible r\te z designat$ by law en=cem5t = em]g5cy vehicle travel44 #bc4 ,m$ic>e treatm5t ( /&by & on-call "t = ,,crna s]vices 7a7 ,9 g5]al ,section #icbj7k7 ( ! ,omnibus ,budget ,reconciliation ,act ( #aihf 7#db ,u4,s4,c4 #aciek note71 z add$ by section #fjh7;c77#b7 ( ! ,family ,support ,act ( #aihh & am5d$ by section #facb ( ! ,omnibus ,budget ,reconciliation ,act ( #aihi1 is am5d$ by add+ at ! end ! foll[+3 7#c7 ,9 det]m9+ ! reasonable co/s incurr$ by a hospital or critical access hospital = ! s]vices ( a c]tifi$ regi/]$ nurse ane/heti/ "u ?is subsection1 ! ,secret>y %all include /&by co/s & on-call co/s incurr$ by ! hospital or critical access hospital1 respectively1 ) respect to su* nurse ane/heti/4 4 7b7 ,effective date ,! am5dm5t made by subsection 7a7 %all apply to co/s incurr$ 9 co/ report+ p]iods beg9n+ 9 fiscal ye>s aft] fiscal ye> #bjje & be=e fiscal ye> #bjae4 #bd4 ,/ate (fices ( rural heal? ,section #cch;,j7j77#a7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bedr7j77#a77 is am5d$ by ins]t+ & #bjae ?r\gh #bjaf be=e ! p]iod4 #be4 ,remov+ ,m$ic>e #if-;h\r physician c]tification requirem5t = inpati5t critical access hospital s]vices 7a7 ,9 g5]al ,section #ahad7;a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7a771 z am5d$ by sections #ab & #ac1 is fur!r am5d$-- 7#a7 9 p>agraph 7#f71 by add+ & at ! end2 7#b7 9 p>agraph 7#g71 at ! end ( subp>agraph 7,d77ii71 by /rik+ 2 & & ins]t+ a p]iod2 & 7#c7 by /rik+ p>agraph 7#h74 7b7 ,application ,! am5dm5ts made by subsection 7a7 %all apply ) respect to items & s]vices furni%$ on or aft] ,janu>y #a1 #bjad4 #bf4 ,ext5sion ( en=cem5t in/ruction on sup]vision requirem5ts = outpati5t !rapeutic s]vices 9 critical access & small rural hospitals ?r\gh #bjad ,! ,secret>y ( ,heal? & ,human ,s]vices %all cont9ue to apply ?r\gh cal5d> ye> #bjad ! en=cem5t in/ruction describ$ 9 ! notice ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices entitl$ ,en=cem5t ,in/ruction on ,sup]vision ,requirem5ts = ,outpati5t ,!rapeutic ,s]vices 9 ,critical ,access & ,small ,rural ,hospitals = ,,cy #bjac1 dat$ ,novemb] #a1 #bjab 7provid+ = an exception to ! 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]vices74