,,ii #aadth ,,congress #b;d ,session ,s4 #cdce ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,september #bh1 #bjaf,mr4 ,roberts 7for himself1 ,mr4 ,franken1 ,mr4 ,barrasso1 and ,ms4 ,heitkamp7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to protect and preserve access of ,medicare beneficiaries in rural areas to health care providers under the ,medicare program1 and for other purposes4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,craig ,thomas ,rural ,hospital and ,provider ,equity ,act of #bjaf4 7b7 ,table of ,contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4 ,sec4 #b4 ,sense of the ,senate4 ,sec4 #c4 ,fairness in the ,medicare disproportionate share hospital 7,,dsh7 adjustment for rural hospitals4 ,sec4 #d4 ,reinstatement and expansion of the ,medicare hold harmless provision under the prospective payment system for hospital outpatient department 7,,hopd7 services for certain hospitals4 ,sec4 #e4 ,extension and temporary improvements to the ,medicare inpatient hospital payment adjustment for low-volume hospitals4 ,sec4 #f4 ,extension of the ,medicare-dependent hospital 7,,mdh7 program4 ,sec4 #g4 ,reinstatement of ,medicare wage index reclassifications for certain hospitals4 ,sec4 #h4 ,extension of ,medicare reasonable costs payments for certain clinical diagnostic laboratory tests furnished to hospital patients in certain rural areas4 ,sec4 #i4 ,elimination of isolation test for cost-based ambulance reimbursement for critical access hospitals4 ,sec4 #aj4 ,capital infrastructure revolving loan program4 ,sec4 #aa4 ,extension of ,medicare incentive payment program for physician scarcity areas4 ,sec4 #ab4 ,extension of floor on ,medicare work geographic adjustment4 ,sec4 #ac4 ,recognition of attending physician assistants as attending physicians to serve hospice patients4 ,sec4 #ad4 ,improving care planning for ,medicare home health services4 ,sec4 #ae4 ,rural health clinic improvements4 ,sec4 #af4 ,temporary ,medicare payment increase for home health services furnished in a rural area4 ,sec4 #ag4 ,extension of increased ,medicare payments for rural ground ambulance services4 ,sec4 #ah4 ,coverage of marriage and family therapist services and mental health counselor services under ,part ,b of the ,medicare program4 ,sec4 #ai4 ,facilitating the provision of telehealth services across ,state lines4 ,sec4 #bj4 ,medicare part ,a payment for anesthesiologist services in certain rural hospitals based on ,,crna pass-through rules4 ,sec4 #ba4 ,temporary floor on the practice expense geographic index for services furnished in rural areas outside of frontier ,states under the ,medicare physician fee schedule4 ,sec4 #bb4 ,revisions to standard for designation of sole community hospitals4 ,sec4 #bc4 ,medicare treatment of standby and on-call time for ,,crna services4 ,sec4 #bd4 ,state offices of rural health4 ,sec4 #be4 ,removing ,medicare #if-;hour physician certification requirement for inpatient critical access hospital services4 ,sec4 #bf4 ,extension of enforcement instruction on supervision requirements for outpatient therapeutic services in critical access and small rural hospitals through #bjag4 ,sec4 #bg4 ,medicare payment for certain rural health clinic and ,federally qualified health center services furnished to hospice patients4 #b4 ,sense of the ,senate ,it is the sense of the ,senate that-- 7#a7 residents of rural and frontier communities should have access to affordable1 quality health care2 7#b7 rural and frontier communities face unique challenges in health care delivery and financing2 7#c7 ,federal health policy must reflect the unique needs of residents of rural and frontier communities and such communities in an equitable and sustainable manner2 and 7#d7 stakeholders should work collectively to identify innovative policies that address the availability1 delivery1 and affordability of health care services in rural and frontier communities4 #c4 ,fairness in the ,medicare disproportionate share hospital 7,,dsh7 adjustment for rural hospitals ,section #ahhf7;d77#e77;,f77xiv77,,ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,f77xiv77,,ii77 is amended by adding at the end the following new sentence3 ,the preceding sentence shall not apply to any hospital with respect to discharges occurring on or after ,october #a1 #bjaf1 and before ,october #a1 #bjag44 #d4 ,reinstatement and expansion of the ,medicare hold harmless provision under the prospective payment system for hospital outpatient department 7,,hopd7 services for certain hospitals ,section #ahcc7t77#g77;,d77i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t77#g77;,d77i77 is amended-- 7#a7 in subclause 7,,ii7-- 7,a7 in the first sentence1 by inserting and for such services furnished on or after ,january #a1 #bjaf1 and before ,january #a1 #bjag1 after covered ,,opd services furnished on or after ,january #a1 #bjjf1 and before ,january #a1 #bjac12 and 7,b7 in the second sentence-- 7i7 by striking and #he and inserting #he2 and 7ii7 by inserting the following before the period at the end3 1 and #ajj percent with respect to such services furnished on or after ,january #a1 #bjaf1 and before ,january #a1 #bjag2 and 7#b7 in subclause 7,,iii7-- 7,a7 in the first sentence-- 7i7 by inserting and for such services furnished on or after ,january #a1 #bjaf1 and before ,january #a1 #bjag1 after covered ,,opd services furnished on or after ,january #a1 #bjji1 and before ,january #a1 #bjac12 and 7ii7 by striking #he percent and inserting the applicable percentage 7as determined under the second sentence of subclause 7,,ii7 for the year72 and 7,b7 in the second sentence1 by inserting and in the case of such services furnished on or after ,january #a1 #bjaf1 and before ,january #a1 #bjag1 after covered ,,opd services furnished on or after ,january #a1 #bjaj1 and before ,march #a1 #bjab14 #e4 ,extension and temporary improvements to the ,medicare inpatient hospital payment adjustment for low-volume hospitals ,section #ahhf7;d77#ab7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#ab77 is amended-- 7#a7 in subparagraph 7,b71 in the matter preceding clause 7i71 by striking fiscal year #bjah and inserting fiscal year #bjai2 7#b7 in subparagraph 7,c77i71 by striking fiscal years #bjaa through #bjag1 #a1fjj discharges of individuals entitled to1 or enrolled for1 benefits under part ,a and inserting fiscal years #bjaa through #bjaf1 #a1fjj discharges of individuals entitled to1 or enrolled for1 benefits under part ,a1 or1 with respect to fiscal years #bjag and #bjah1 #b1jjj discharges of such individuals2 and 7#c7 in subparagraph 7,d7-- 7,a7 by striking #a1fjj and inserting the applicable number of2 and 7,b7 by adding at the end the following new sentence3 ,for purposes of the preceding sentence1 the term applicable number of discharges means #a1fjj discharges with respect to discharges occurring in fiscal years #bjaa through #bjaf1 and #b1jjj discharges with respect to discharges occurring in fiscal years #bjag and #bjah44 #f4 ,extension of the ,medicare-dependent hospital 7,,mdh7 program 7a7 ,in general ,section #ahhf7;d77#e77;,g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,g77 is amended-- 7#a7 in clause 7i71 by striking ,october #a1 #bjag and inserting ,october #a1 #bjah2 and 7#b7 in clause 7ii77,,ii71 by striking ,october #a1 #bjag and inserting ,october #a1 #bjah4 7b7 ,conforming amendments 7#a7 ,extension of target amount ,section #ahhf7;b77#c77;,d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7b77#c77;,d77 is amended-- 7,a7 in the matter preceding clause 7i71 by striking ,october #a1 #bjag and inserting ,october #a1 #bjah2 and 7,b7 in clause 7iv71 by striking through fiscal year #bjag and inserting through fiscal year #bjah4 7#b7 ,permitting hospitals to decline reclassification ,section #aceja7;e77#b7 of the ,omnibus ,budget ,reconciliation ,act of #aiic 7#db ,u4,s4,c4 #acieww note7 is amended by striking through fiscal year #bjag and inserting through fiscal year #bjah4 #g4 ,reinstatement of ,medicare wage index reclassifications for certain hospitals 7a7 ,reinstatement of correction of mid-,year reclassification expiration for certain hospitals 7#a7 ,in general ,the first sentence of subsection 7a7 of section #ajf of division ,b of the ,tax ,relief and ,health ,care ,act of #bjjf 7#db ,u4,s4,c4 #acieww note71 as amended by section #aag of the ,medicare1 ,medicaid1 and ,,schip ,extension ,act of #bjjg 7,public ,law #aaj-agc71 section #abd of the ,medicare ,improvements for ,patients and ,providers ,act of #bjjh 7,public ,law #aaj-bge71 sections #cacg7;a7 and #ajcag of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh71 section #ajb of the ,medicare and ,medicaid ,extenders ,act of #bjaj 7,public ,law #aaa-cji71 section #cjb7;a7 of the ,temporary ,payroll ,tax ,cut ,continuation ,act of #bjaa 7,public ,law #aab-gh71 and section #cjja7;a7 of the ,middle ,class ,tax ,relief and ,job ,creation ,act of #bjab 7,public ,law #aab-if71 is amended by inserting and1 in the case of a hospital described in section #g7;a77#b7 of the ,craig ,thomas ,rural ,hospital and ,provider ,equity ,act of #bjaf1 shall apply such reclassification of such hospital during the period beginning on ,january #a1 #bjaf1 and ending on ,december #ca1 #bjaf before the period at the end4 7#b7 ,hospital described ,a hospital described in this paragraph is-- 7,a7 a hospital-- 7i7 that is described in such subsection 7a7 such section #ajf2 and 7ii7 7,i7 that is located in a rural area2 and 7,,ii7 for which the ,secretary has determined the reinstatement under the provisions of1 and amendments made by1 this section is appropriate2 or 7,b7 a sole community hospital located in a ,state with less than #aj people per square mile that was provided with a special exception reclassification extension under section #aag7;a77#b7 of the ,medicare1 ,medicaid1 and ,,schip ,extension ,act of #bjjg4 7b7 ,not budget neutral ,the provisions of1 and amendments made by1 this section shall not be effected in a budget-neutral manner4 #h4 ,extension of ,medicare reasonable costs payments for certain clinical diagnostic laboratory tests furnished to hospital patients in certain rural areas ,section #daf7;b7 of the ,medicare ,prescription ,drug1 ,improvement1 and ,modernization ,act of #bjjc 7#db ,u4,s4,c4 #aciel71 as amended by section #aje of division ,b of the ,tax ,relief and ,health ,care ,act of #bjjf 7#db ,u4,s4,c4 #aciel note71 section #ajg of the ,medicare1 ,medicaid1 and ,,schip ,extension ,act of #bjjg 7#db ,u4,s4,c4 #aciel note71 section #cabb of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh71 and section #aji of the ,medicare and ,medicaid ,extenders ,act of #bjaj 7,public ,law #aaa-cji71 is amended-- 7#a7 by striking or during the #b-year and inserting 1 during the #b-year2 and 7#b7 by inserting 1 or during the #a-year period beginning on ,january #a1 #bjag before the period at the end4 #i4 ,elimination of isolation test for cost-based ambulance reimbursement for critical access hospitals 7a7 ,in general ,section #ahcd7l77#h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l77#h77 is amended-- 7#a7 in subparagraph 7,b7-- 7,a7 by striking owned and2 and 7,b7 by inserting 7including when such services are provided by the entity under an arrangement with the hospital7 after hospital2 and 7#b7 by striking the comma at the end of subparagraph 7,b7 and all that follows and inserting a period4 7b7 ,effective date ,the amendments made by this section shall apply to services furnished on or after ,january #a1 #bjag4 #aj4 ,capital infrastructure revolving loan program 7a7 ,in ,general ,part ,a of title ,,xvi of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjjq et seq47 is amended by adding at the end the following new section3 #afjc4 ,capital infrastructure revolving loan program 7a7 ,authority ,to ,make and ,guarantee ,loans 7#a7 ,authority to make loans ,the ,secretary may make loans from the fund established under section #afjb7;d7 to any rural entity for projects for capital improvements1 including-- 7,a7 the acquisition of land necessary for the capital improvements2 7,b7 the renovation or modernization of any building2 7,c7 the acquisition or repair of fixed or major movable equipment2 and 7,d7 such other project expenses as the ,secretary determines appropriate4 7#b7 ,authority to guarantee loans 7,a7 ,in general ,the ,secretary may guarantee the payment of principal and interest for loans made to rural entities for projects for any capital improvement described in paragraph 7#a7 to any non-,federal lender4 7,b7 ,interest subsidies ,in the case of a guarantee of any loan made to a rural entity under subparagraph 7,a71 the ,secretary may pay to the holder of such loan1 for and on behalf of the project for which the loan was made1 amounts sufficient to reduce 7by not more than #c percent7 the net effective interest rate otherwise payable on such loan4 7b7 ,amount of ,loan ,the principal amount of a loan directly made or guaranteed under subsection 7a7 for a project for capital improvement may not exceed #e1jjj1jjj4 7c7 ,funding ,limitations 7#a7 ,government credit subsidy exposure ,the total of the ,government credit subsidy exposure under the ,federal ,credit ,reform ,act of #aiij scoring protocol with respect to the loans outstanding at any time with respect to which guarantees have been issued1 or which have been directly made1 under subsection 7a7 may not exceed #ej1jjj1jjj per year4 7#b7 ,total amounts ,subject to paragraph 7#a71 the total of the principal amount of all loans directly made or guaranteed under subsection 7a7 may not exceed #bej1jjj1jjj per year4 7d7 ,capital ,assessment and ,planning ,grants 7#a7 ,nonrepayable grants ,subject to paragraph 7#b71 the ,secretary may make a grant to a rural entity1 in an amount not to exceed #ej1jjj1 for purposes of capital assessment and business planning4 7#b7 ,limitation ,the cumulative total of grants awarded under this subsection may not exceed #b1ejj1jjj per year4 7e7 ,termination of ,authority ,the ,secretary may not directly make or guarantee any loan under subsection 7a7 or make a grant under subsection 7d7 after ,january #a1 #bjag4 4 7b7 ,rural ,entity ,defined ,section #afbd of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjjs-#c7 is amended by adding at the end the following new paragraph3 7#ae7 7,a7 ,the term rural entity includes-- 7i7 a rural health clinic1 as defined in section #ahfa7;aa77#b7 of the ,social ,security ,act2 7ii7 any medical facility with at least #a bed1 but with less than #ej beds1 that is located in-- 7,i7 a county that is not part of a metropolitan statistical area2 or 7,,ii7 a rural census tract of a metropolitan statistical area 7as determined under the most recent modification of the ,goldsmith ,modification1 originally published in the ,federal ,register on ,february #bg1 #aiib 7#eg ,fed4 ,reg4 #fgbe772 7iii7 a hospital that is classified as a rural1 regional1 or national referral center under section #ahhf7;d77#e77;,c7 of the ,social ,security ,act2 and 7iv7 a hospital that is a sole community hospital 7as defined in section #ahhf7;d77#e77;,d77iii7 of the ,social ,security ,act74 7,b7 ,for purposes of subparagraph 7,a71 the fact that a clinic1 facility1 or hospital has been geographically reclassified under the ,medicare program under title ,,xviii of the ,social ,security ,act shall not preclude a hospital from being considered a rural entity under clause 7i7 or 7ii7 of subparagraph 7,a74 4 7c7 ,conforming ,amendments ,section #afjb of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjjq-#b7 is amended-- 7#a7 in subsection 7b77#b77;,d71 by inserting or #afjc7;a77#b77;,b7 after #afja7;a77#b77;,b72 and 7#b7 in subsection 7d7-- 7,a7 in paragraph 7#a77;,c71 by striking section #afja7;a77#b77;,b7 and inserting sections #afja7;a77#b77;,b7 and #afjc7;a77#b77;,b72 and 7,b7 in paragraph 7#b77;,a71 by inserting or #afjc7;a77#b77;,b7 after #afja7;a77#b77;,b74 #aa4 ,extension of ,medicare incentive payment program for physician scarcity areas ,section #ahcc7u77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7u77#a77 is amended by inserting 1 and such services furnished on or after ,april #a1 #bjaf1 and before ,april #a1 #bjag after #bjjh4 #ab4 ,extension of floor on ,medicare work geographic adjustment ,section #ahdh7;e77#a77;,e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;e77#a77;,e77 is amended by striking ,january #a1 #bjah and inserting ,january #a1 #bjai4 #ac4 ,recognition of attending physician assistants as attending physicians to serve hospice patients 7a7 ,in ,general ,section #ahfa7;dd77#c77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7dd77#c77;,b77 is amended-- 7#a7 by striking or nurse practitioner and inserting 1 the nurse practitioner2 and 7#b7 by inserting 1 or the physician assistant 7as defined in such subsection7 after subsection 7aa77#e774 7b7 ,permitting physician assistants when delegated by a physician ,to order hospice care ,section #ahad7;a77#g77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7a77#g77;,a77 is amended-- 7#a7 in clause 7i77,i71 by striking does not include a nurse practitioner and inserting only includes a physician assistant if a physician has delegated the authority to make the certification required under this paragraph to such physician assistant2 and 7#b7 by amending clause 7ii7 to read as follows3 7ii7 in a subsequent #ij- or #fj-;day period-- 7,i7 the medical director or physician described in clause 7i77,,ii72 7,,ii7 a physician employed by the hospice program providing 7or arranging for7 the care or providing care to the individual under arrangement with such hospice program2 7,,iii7 a nurse practitioner employed by such hospice program or providing care to the individual under arrangement with such hospice program2 or 7,,iv7 a physician assistant employed by such hospice program or providing care to the individual under arrangement with such hospice program1 provided that an individual described in subclause 7,i7 or 7,,ii7 has delegated the authority to make the recertification required under this clause to such physician assistant1 recertifies at the beginning of the period that the individual is terminally ill based on such clinical judgment2 4 7c7 ,effective date ,the amendments made by this section shall apply to items and services furnished on or after ,january #a1 #bjag4 #ad4 ,improving care planning for ,medicare home health services 7a7 ,part ,a provisions ,section #ahad7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7a77 is amended-- 7#a7 in paragraph 7#b7-- 7,a7 in the matter preceding subparagraph 7,a71 by inserting 1 a nurse practitioner or clinical nurse specialist who is working in collaboration with a physician in accordance with ,state law1 a certified nurse-midwife 7as defined in section #ahfa7;gg77 as authorized by ,state law1 or a physician assistant 7as defined in section #ahfa7;aa77#e77 under the supervision of a physician after #ahff7;j72 and 7,b7 in subparagraph 7,c7-- 7i7 by inserting 1 a nurse practitioner1 a clinical nurse specialist1 a certified nurse-midwife1 or a physician assistant 7as the case may be7 after physician the first #b times it appears2 and 7ii7 by striking 1 and1 in the case of a certification made by a physician and all that follows through face-to-face encounter and inserting 1 and1 in the case of a certification made by a physician after ,january #a1 #bjaj1 or by a nurse practitioner1 clinical nurse specialist1 certified nurse-midwife1 or physician assistant 7as the case may be7 after ,january #a1 #bjag1 prior to making such certification the physician1 nurse practitioner1 clinical nurse specialist1 certified nurse-midwife1 or physician assistant must document that the physician1 nurse practitioner1 clinical nurse specialist1 certified nurse-midwife1 or physician assistant has had a face-to-face encounter2 and 7#b7 in the flush matter following paragraph 7#h7-- 7,a7 in the first sentence1 by inserting certified nurse-midwife1 after clinical nurse specialist12 7,b7 in the second sentence-- 7i7 by striking physician certification and inserting certification2 7ii7 by inserting 7or on ,january #a1 #bjag1 in the case of regulations to implement the amendments made by section #ad of the ,craig ,thomas ,rural ,hospital and ,provider ,equity ,act of #bjaf7 after #aiha2 and 7iii7 by striking a physician who and inserting a physician1 nurse practitioner1 clinical nurse specialist1 certified nurse-midwife1 or physician assistant who2 and 7,c7 in the third sentence1 by inserting 1 nurse practitioner1 clinical nurse specialist1 certified nurse-midwife1 or physician assistant after physician4 7b7 ,part ,b provisions ,section #ahce7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acien7a77 is amended-- 7#a7 in paragraph 7#b7-- 7,a7 in the matter preceding subparagraph 7,a71 by inserting 1 a nurse practitioner or clinical nurse specialist 7as those terms are defined in section #ahfa7;aa77#e77 who is working in collaboration with a physician in accordance with ,state law1 a certified nurse-midwife 7as defined in section #ahfa7;gg77 as authorized by ,state law1 or a physician assistant 7as defined in section #ahfa7;aa77#e77 under the supervision of a physician after #ahff7;j72 and 7,b7 in subparagraph 7,a7-- 7i7 in each of clauses 7ii7 and 7iii7 of subparagraph 7,a71 by inserting 1 a nurse practitioner1 a clinical nurse specialist1 a certified nurse-midwife1 or a physician assistant 7as the case may be7 after physician2 and 7ii7 in clause 7iv71 by striking after ,january #a1 #bjaj and all that follows through face-to-face encounter and inserting made by a physician after ,january #a1 #bjaj1 or by a nurse practitioner1 clinical nurse specialist1 certified nurse-midwife1 or physician assistant 7as the case may be7 after ,january #a1 #bjag1 prior to making such certification the physician1 nurse practitioner1 clinical nurse specialist1 certified nurse-midwife1 or physician assistant must document that the physician1 nurse practitioner1 clinical nurse specialist1 certified nurse-midwife1 or physician assistant has had a face-to-face encounter2 7#b7 in the third sentence1 by inserting 1 nurse practitioner1 clinical nurse specialist1 certified nurse-midwife1 or physician assistant 7as the case may be7 after physician2 7#c7 in the fourth sentence-- 7,a7 by striking physician certification and inserting certification2 7,b7 by inserting 7or on ,january #a1 #bjag1 in the case of regulations to implement the amendments made by section #ad of the ,craig ,thomas ,rural ,hospital and ,provider ,equity ,act of #bjaf7 after #aiha2 and 7,c7 by striking a physician who and inserting a physician1 nurse practitioner1 clinical nurse specialist1 certified nurse-midwife1 or physician assistant who2 and 7#d7 in the fifth sentence1 by inserting 1 nurse practitioner1 clinical nurse specialist1 certified nurse-midwife1 or physician assistant after physician4 7c7 ,definition provisions 7#a7 ,home health services ,section #ahfa7m7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7m77 is amended-- 7,a7 in the matter preceding paragraph 7#a7-- 7i7 by inserting 1 a nurse practitioner or a clinical nurse specialist 7as those terms are defined in subsection 7aa77#e771 a certified nurse-midwife 7as defined in section #ahfa7;gg771 or a physician assistant 7as defined in subsection 7aa77#e77 after physician the first place it appears2 and 7ii7 by inserting 1 a nurse practitioner1 a clinical nurse specialist1 a certified nurse-midwife1 or a physician assistant after physician the second place it appears2 and 7,b7 in paragraph 7#c71 by inserting 1 a nurse practitioner1 a clinical nurse specialist1 a certified nurse-midwife1 or a physician assistant after physician4 7#b7 ,home health agency ,section #ahfa7o77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7o77#b77 is amended-- 7,a7 by inserting 1 nurse practitioners or clinical nurse specialists 7as those terms are defined in subsection 7aa77#e771 certified nurse-midwives 7as defined in section #ahfa7;gg771 or physician assistants 7as defined in subsection 7aa77#e77 after physicians2 and 7,b7 by inserting 1 nurse practitioner1 clinical nurse specialist1 certified nurse-midwife1 physician assistant1 after physician4 7d7 ,home health prospective payment system provisions ,section #ahie of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;fff7 is amended-- 7#a7 in subsection 7c77#a71 by inserting 1 the nurse practitioner or clinical nurse specialist 7as those terms are defined in section #ahfa7;aa77#e771 the certified nurse-midwife 7as defined in section #ahfa7;gg771 or the physician assistant 7as defined in section #ahfa7;aa77#e771 after physician2 and 7#b7 in subsection 7e7-- 7,a7 in paragraph 7#a77;,a71 by inserting 1 a nurse practitioner or clinical nurse specialist 7as those terms are defined in section #ahfa7;aa77#e771 a certified nurse-midwife 7as defined in section #ahfa7;gg771 or a physician assistant 7as defined in section #ahfa7;aa77#e77 after physician2 and 7,b7 in paragraph 7#b7-- 7i7 in the heading1 by striking ,physician certification and inserting ,rule of construction regarding requirement for certification2 and 7ii7 by striking physician4 7e7 ,effective ,date ,the amendments made by this section shall apply to items and services furnished on or after ,january #a1 #bjag4 #ae4 ,rural health clinic improvements ,section #ahcc7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7f77 is amended-- 7#a7 in paragraph 7#a71 by striking 1 and at the end and inserting a semicolon2 7#b7 in paragraph 7#b7-- 7,a7 by inserting 7before #bjag7 after in a subsequent year2 and 7,b7 by striking the period at the end and inserting a semicolon2 and 7#c7 by adding at the end the following new paragraphs3 7#c7 in #bjag1 at #aaj per visit2 and 7#d7 for years following #bjag1 at the limit established under this subsection for the previous year increased by the percentage increase in the ,,mei 7as so defined7 applicable to primary care services 7as so defined7 furnished as of the first day of that year4 4 #af4 ,temporary ,medicare payment increase for home health services furnished in a rural area ,section #dba7;a7 of the ,medicare ,prescription ,drug1 ,improvement1 and ,modernization ,act of #bjjc 7,public ,law #ajh-agc2 #aag ,stat4 #bbhc71 as amended by section #ebja7;b7 of the ,deficit ,reduction ,act of #bjje 7,public ,law #aji-aga2 #abj ,stat4 #df71 section #caca7;c7 of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh2 #abd ,stat4 #dbh71 and section #baj of the ,medicare ,access and ,,chip ,reauthorization ,act of #bjae 7,public ,law #aad-aj2 #abi ,stat4 #aea71 is amended by striking ,january #a1 #bjah and inserting ,january #a1 #bjai each place it appears4 #ag4 ,extension of increased ,medicare payments for rural ground ambulance services 7a7 ,in general ,section #ahcd7l77#ac77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l77#ac77;,a77 is amended-- 7#a7 in the matter preceding clause 7i71 by striking ,july #a1 #bjjd and all that follows through originates in2 7#b7 in clause 7i7-- 7,a7 by inserting ,july #a1 #bjjd1 and before ,january #a1 #bjjg1 and for such services furnished on or after ,july #a1 #bjjh1 and before ,january #a1 #bjai1 for which the transportation originates in before a rural2 and 7,b7 by striking #bjah and inserting #bjag1 or #e percent if such service is furnished on or after ,january #a1 #bjag1 and before ,january #a1 #bjai2 and 7#c7 in clause 7ii71 by inserting ,july #a1 #bjjd1 and before ,january #a1 #bjjg1 and for such services furnished on or after ,july #a1 #bjjh1 and before ,january #a1 #bjah1 for which the transportation originates in before an area not4 7b7 ,super rural ambulance ,section #ahcd7l77#ab77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l77#ab77;,a77 is amended by striking ,january #a1 #bjah and inserting ,january #a1 #bjai4 #ah4 ,coverage of marriage and family therapist services and mental health counselor services under ,part ,b of the ,medicare program 7a7 ,coverage of ,services 7#a7 ,in general ,section #ahfa7s77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7s77#b77 is amended-- 7,a7 in subparagraph 7,,ee71 by striking and after the semicolon at the end2 7,b7 in subparagraph 7,,ff71 by inserting and after the semicolon at the end2 and 7,c7 by adding at the end the following new subparagraph3 7,,gg7 marriage and family therapist services 7as defined in subsection 7iii77#a77 and mental health counselor services 7as defined in subsection 7iii77#c772 4 7#b7 ,definitions ,section #ahfa of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7 is amended by adding at the end the following new subsection3 7iii7 ,marriage and ,family ,therapist ,services2 ,marriage and ,family ,therapist2 ,mental ,health ,counselor ,services2 ,mental ,health ,counselor 7#a7 ,the term marriage and family therapist services means services performed by a marriage and family therapist 7as defined in paragraph 7#b77 for the diagnosis and treatment of mental illnesses1 which the marriage and family therapist is legally authorized to perform under ,state law 7or the ,state regulatory mechanism provided by ,state law7 of the ,state in which such services are performed1 as would otherwise be covered if furnished by a physician or as an incident to a physician's professional service1 but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services4 7#b7 ,the term marriage and family therapist means an individual who-- 7,a7 possesses a master's or doctoral degree which qualifies for licensure or certification as a marriage and family therapist pursuant to ,state law2 7,b7 after obtaining such degree has performed at least #b years of clinical supervised experience in marriage and family therapy2 and 7,c7 in the case of an individual performing services in a ,state that provides for licensure or certification of marriage and family therapists1 is licensed or certified as a marriage and family therapist in such ,state4 7#c7 ,the term mental health counselor services means services performed by a mental health counselor 7as defined in paragraph 7#d77 for the diagnosis and treatment of mental illnesses which the mental health counselor is legally authorized to perform under ,state law 7or the ,state regulatory mechanism provided by the ,state law7 of the ,state in which such services are performed1 as would otherwise be covered if furnished by a physician or as incident to a physician's professional service1 but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services4 7#d7 ,the term mental health counselor means an individual who-- 7,a7 possesses a master's or doctor's degree in mental health counseling or a related field2 7,b7 after obtaining such a degree has performed at least #b years of supervised mental health counselor practice2 and 7,c7 in the case of an individual performing services in a ,state that provides for licensure or certification of mental health counselors or professional counselors1 is licensed or certified as a mental health counselor or professional counselor in such ,state4 4 7#c7 ,provision for payment under part ,b ,section #ahcb7;a77#b77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciek7a77#b77;,b77 is amended by adding at the end the following new clause3 7v7 marriage and family therapist services 7as defined in section #ahfa7;iii77#a77 and mental health counselor services 7as defined in section #ahfa7;iii77#c772 4 7#d7 ,amount of payment ,section #ahcc7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7a77#a77 is amended-- 7,a7 by striking and 7,,aa7 and inserting 7,,aa72 and 7,b7 by inserting before the semicolon at the end the following3 1 and 7,,bb7 with respect to marriage and family therapist services and mental health counselor services under section #ahfa7s77#b77;,,gg71 the amounts paid shall be #hj percent of the lesser of the actual charge for the services or #ge percent of the amount determined for payment of a psychologist under subparagraph 7,l74 7#e7 ,exclusion of marriage and family therapist services and mental health counselor services from skilled nursing facility prospective payment system ,section #ahhh7;e77#b77;,a77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieyy7e77#b77;,a77ii77 is amended by inserting marriage and family therapist services 7as defined in section #ahfa7;iii77#a771 mental health counselor services 7as defined in section #ahfa7;iii77#c771 after qualified psychologist services14 7#f7 ,inclusion of marriage and family therapists and mental health counselors as practitioners for assignment of claims ,section #ahdb7;b77#ah77;,c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieu7b77#ah77;,c77 is amended by adding at the end the following new clauses3 7vii7 ,a marriage and family therapist 7as defined in section #ahfa7;iii77#b774 7viii7 ,a mental health counselor 7as defined in section #ahfa7;iii77#d774 4 7b7 ,coverage of ,certain ,mental ,health ,services ,provided in ,certain ,settings 7#a7 ,rural health clinics and federally qualified health centers ,section #ahfa7;aa77#a77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7aa77#a77;,b77 is amended by striking or by a clinical social worker 7as defined in subsection 7hh77#a77 and inserting 1 by a clinical social worker 7as defined in subsection 7hh77#a771 by a marriage and family therapist 7as defined in subsection 7iii77#b771 or by a mental health counselor 7as defined in subsection 7iii77#d774 7#b7 ,hospice programs ,section #ahfa7;dd77#b77;,b77i77,,iii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7dd77#b77;,b77i77,,iii77 is amended by inserting 1 marriage and family therapist1 or mental health counselor after social worker4 7c7 ,authorization of marriage and family therapists and mental health counselors ,to develop discharge plans for post-,hospital services ,section #ahfa7;ee77#b77;,g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7ee77#b77;,g77 is amended by inserting 1 including a marriage and family therapist and a mental health counselor who meets qualification standards established by the ,secretary before the period at the end4 7d7 ,effective ,date ,the amendments made by this section shall apply with respect to services furnished on or after ,january #a1 #bjag4 #ai4 ,facilitating the provision of telehealth services across ,state lines 7a7 ,in general ,for purposes of expediting the provision of telehealth services1 for which payment is made under the ,medicare program1 across ,state lines1 the ,secretary of ,health and ,human ,services shall1 in consultation with representatives of ,states1 physicians1 health care practitioners1 and patient advocates1 encourage and facilitate the adoption of provisions allowing for multistate practitioner practice across ,state lines4 7b7 ,definitions ,in subsection 7a73 7#a7 ,telehealth service ,the term telehealth service has the meaning given that term in subparagraph 7,f7 of section #ahcd7m77#d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7m77#d774 7#b7 ,physician1 practitioner ,the terms physician and practitioner have the meaning given those terms in subparagraphs 7,d7 and 7,e71 respectively1 of such section4 7#c7 ,medicare program ,the term ,medicare program means the program of health insurance administered by the ,secretary of ,health and ,human ,services under title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq474 #bj4 ,medicare part ,a payment for anesthesiologist services in certain rural hospitals based on ,,crna pass-through rules 7a7 ,in ,general ,section #ahad of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7 is amended by adding at the end the following new subsection3 7m7 ,anesthesiologist ,services ,provided in ,certain ,rural ,hospitals 7#a7 ,notwithstanding any other provision of this title1 coverage and payment shall be provided under this part for physicians' services that are anesthesia services furnished by a physician who is an anesthesiologist in a rural hospital described in paragraph 7#c7 in the same manner as payment is made under the exception provided in section #icbj7k7 of the ,omnibus ,budget ,reconciliation ,act of #aihf1 as amended by section #facb of the ,omnibus ,budget ,reconciliation ,act of #aihi 7#db ,u4,s4,c4 #aciek note7 7relating to payment on a reasonable cost1 pass-through basis71 for certified registered nurse anesthetist services furnished by a certified registered nurse anesthetist in a hospital described in such section4 7#b7 ,no payment shall be made under any other provision of this title for physicians' services for which payment is made under this subsection4 7#c7 ,a rural hospital described in this paragraph is a hospital described in section #icbj7k7 of the ,omnibus ,budget ,reconciliation ,act of #aihf1 as so amended 7#db ,u4,s4,c4 #aciek note71 except that-- 7,a7 any reference in such section to a certified registered nurse anesthetist or anesthetist is deemed a reference to a physician who is an anesthesiologist or anesthesiologist1 respectively2 and 7,b7 any reference to ,january #a1 #aihh or #aihg is deemed a reference to such date and year as the ,secretary shall specify4 4 7b7 ,effective ,date ,the amendment made by subsection 7a7 shall apply to services furnished during cost reporting periods beginning on or after the date of the enactment of this ,act4 #ba4 ,temporary floor on the practice expense geographic index for services furnished in rural areas outside of frontier ,states under the ,medicare physician fee schedule ,section #ahdh7;e77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;e77#a77 is amended by adding at the end the following new subparagraph3 7,j7 ,floor at #a4j on practice expense geographic index for services furnished in rural areas outside of frontier ,states ,for purposes of payment for services furnished in a rural area 7other than a rural area located in a ,state to which subparagraph 7,i7 applies7 on or after ,january #a1 #bjag1 and before ,january #a1 #bjah1 after calculating the practice expense index under subparagraph 7,a77i71 the ,secretary shall increase any such index to #a4j if such index would otherwise be less than #a4j4 ,the preceding sentence shall not be applied in a budget neutral manner4 4 #bb4 ,revisions to standard for designation of sole community hospitals ,section #ahhf7;d77#e77;,d77iv7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,d77iv77 is amended by adding at the end the following new sentence3 ,under such standard1 the time required for an individual to travel to the nearest alternative source of care shall be measured over improved roads maintained by a local1 ,state1 or ,federal ,government entity for use by the general public which is the most expeditious and accessible route as designated by law enforcement for emergency vehicle travel44 #bc4 ,medicare treatment of standby and on-call time for ,,crna services 7a7 ,in general ,section #icbj7k7 of the ,omnibus ,budget ,reconciliation ,act of #aihf 7#db ,u4,s4,c4 #aciek note71 as added by section #fjh7;c77#b7 of the ,family ,support ,act of #aihh and amended by section #facb of the ,omnibus ,budget ,reconciliation ,act of #aihi1 is amended by adding at the end the following3 7#c7 ,in determining the reasonable costs incurred by a hospital or critical access hospital for the services of a certified registered nurse anesthetist under this subsection1 the ,secretary shall include standby costs and on-call costs incurred by the hospital or critical access hospital1 respectively1 with respect to such nurse anesthetist4 4 7b7 ,effective date ,the amendment made by subsection 7a7 shall apply to costs incurred in cost reporting periods beginning in fiscal years after fiscal year #bjjg and before fiscal year #bjag4 #bd4 ,state offices of rural health ,section #cch;,j of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bedr7 is amended to read as follows3 #cch;,j4 ,grants to ,state offices of rural health 7a7 ,in general ,the ,secretary1 acting through the ,director of the ,federal ,office of ,rural ,health ,policy 7established under section #gaa of the ,social ,security ,act71 shall make grants to each ,state ,office of ,rural ,health for the purpose of improving health care in rural areas4 7b7 ,requirement of matching funds 7#a7 ,in general ,subject to paragraph 7#b71 the ,secretary may not make a grant under subsection 7a7 unless the ,state office of rural health involved agrees1 with respect to the costs to be incurred in carrying out the purpose described in such subsection1 to provide non-,federal contributions toward such costs in an amount equal to #c for each #a of ,federal funds provided in the grant4 7#b7 ,waiver or ,reduction ,the ,secretary is authorized to waive or reduce the non-,federal contribution if the ,state office of rural health can demonstrate that requiring matching funds would limit its ability to carry out the purpose described in subsection 7a74 7#c7 ,determination of amount of non-,federal contribution ,non-,federal contributions required in paragraph 7#a7 may be in cash or in kind1 fairly evaluated1 including plant1 equipment1 or services4 ,amounts provided by the ,federal ,government1 or services assisted or subsidized to any significant extent by the ,federal ,government1 may not be included in determining the amount of such non-,federal contributions4 7c7 ,certain required activities ,recipients of a grant under subsection 7a7 shall use the grant funds for purposes of-- 7#a7 maintaining within the ,state office of rural health a clearinghouse for collecting and disseminating information on-- 7,a7 rural health care issues2 7,b7 research findings relating to rural health care2 and 7,c7 innovative approaches to the delivery of health care in rural areas2 7#b7 coordinating the activities carried out in the ,state that relate to rural health care1 including providing coordination for the purpose of avoiding redundancy in such activities2 and 7#c7 identifying ,federal and ,state programs regarding rural health1 and providing technical assistance to public and nonprofit private entities regarding participation in such programs4 7d7 ,requirement regarding annual budget for office ,the ,secretary may not make a grant under subsection 7a7 unless the ,state involved agrees that1 for any fiscal year for which the ,state office of rural health receives such a grant1 the office operated pursuant to subsection 7a7 of this section will be provided with an annual budget of not less than #aej1jjj4 7e7 ,certain uses of funds 7#a7 ,restrictions ,the ,secretary may not make a grant under subsection 7a7 unless the ,state office of rural health involved agrees that the grant will not be expended-- 7,a7 to provide health care 7including providing cash payments regarding such care72 7,b7 to conduct activities for which ,federal funds are expended-- 7i7 within the ,state to provide technical and other nonfinancial assistance under section #ccj;,a7f72 7ii7 under a memorandum of agreement entered into with the ,state office of rural health under section #ccj;,a7h72 or 7iii7 under a grant under section #cch;,i2 7,c7 to purchase medical equipment1 to purchase ambulances1 aircraft1 or other vehicles1 or to purchase major communications equipment2 7,d7 to purchase or improve real property2 or 7,e7 to carry out any activity regarding a certificate of need4 7#b7 ,authorities ,activities for which a ,state office of rural health may expend a grant under subsection 7a7 include-- 7,a7 paying the costs of maintaining an office of rural health for purposes of subsection 7a72 7,b7 subject to paragraph 7#a77;,b77iii71 paying the costs of any activity carried out with respect to recruiting and retaining health professionals to serve in rural areas of the ,state2 and 7,c7 providing grants and contracts to public and nonprofit private entities to carry out activities authorized in this section4 7#c7 ,limit on ,indirect ,costs ,the ,secretary may impose a limit of no more than #ae percent on indirect costs claimed by the recipient of the grant4 7f7 ,reports ,the ,secretary may not make a grant under subsection 7a7 unless the ,state office of rural health involved agrees-- 7#a7 to submit to the ,secretary reports or performance data containing such information as the ,secretary may require regarding activities carried out under this section2 and 7#b7 to submit such a report or performance data not later than than ,september #cj of any fiscal year for which the ,state office of rural health has received such a grant4 7g7 ,requirement of application ,the ,secretary may not make a grant under subsection 7a7 unless an application for the grant is submitted to the ,secretary and the application is in such form1 is made in such manner1 and contains such agreements1 assurances1 and information as the ,secretary determines to be necessary to carry out such subsection4 7h7 ,noncompliance ,the ,secretary may not make payments under subsection 7a7 to a ,state office of rural health for any fiscal year subsequent to the first fiscal year of such payments unless the ,secretary determines that1 for the immediately preceding fiscal year1 the ,state office of rural health has complied with each of the agreements made by the ,state office of rural health under this section4 7i7 ,authorization of appropriations 7#a7 ,in general ,for the purpose of making grants under subsection 7a71 there are authorized to be appropriated such sums as may be necessary for each of fiscal years #bjag through #bjba4 7#b7 ,availability ,amounts appropriated under paragraph 7#a7 shall remain available until expended4 4 #be4 ,removing ,medicare #if-;hour physician certification requirement for inpatient critical access hospital services 7a7 ,in general ,section #ahad7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7a771 is amended-- 7#a7 in paragraph 7#f71 by adding and at the end2 7#b7 in paragraph 7#g71 at the end of subparagraph 7,e71 by striking 2 and and inserting a period2 and 7#c7 by striking paragraph 7#h74 7b7 ,application ,the amendments made by subsection 7a7 shall apply with respect to items and services furnished on or after ,january #a1 #bjag4 #bf4 ,extension of enforcement instruction on supervision requirements for outpatient therapeutic services in critical access and small rural hospitals through #bjag ,section #a of ,public ,law #aac-aih1 as amended by section #a of ,public ,law #aad-aab1 is amended-- 7#a7 in the section heading1 by striking and #bjae and inserting 1 #bjae1 #bjaf1 and #bjag2 and 7#b7 by striking and #bjae and inserting 1 #bjae1 #bjaf1 and #bjag4 #bg4 ,medicare payment for certain rural health clinic and ,federally qualified health center services furnished to hospice patients 7a7 ,in general ,section #ahab7;d77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;d7d77#b77 is amended-- 7#a7 in subparagraph 7,a7-- 7,a7 in the matter preceding clause 7i71 by striking subparagraphs 7,b7 and 7,c7 and inserting the succeeding provisions of this paragraph2 7,b7 in clause 7ii77,,ii71 by striking the semicolon at the end and inserting a period2 and 7,c7 by striking the flush matter following clause 7ii77,,ii72 and 7#b7 by adding at the end the following new subparagraph3 7,e7 ,subparagraph 7,a77ii7 shall not apply to-- 7i7 physicians' services furnished by the individual's attending physician 7as defined in section #ahfa7;dd77#c77;,b771 if not an employee of the hospice program2 7ii7 services provided by 7or under arrangements made by7 the hospice program2 or 7iii7 rural health clinic services 7as defined in paragraph 7#a7 of section #ahfa7;aa77 and ,federally qualified health center services 7as defined in paragraph 7#c7 of such section7 if such services-- 7,i7 would otherwise be physicians' services if furnished by an individual not affiliated with a rural health clinic 7as defined in paragraph 7#b7 of such section7 or a ,federally qualified health center 7as defined in paragraph 7#d7 of such section72 and 7,,ii7 are-- 7aa7 furnished by the individual's attending physician 7as so defined71 if not an employee of the hospice program2 or 7bb7 provided under arrangements made by the hospice program4 4 7b7 ,effective date ,the amendments made by this section shall apply to services furnished on or after the date that is six months after the date of the enactment of this ,act4