,,ii  #aaeth ,,congress  #ast ,session  
,s4 #ahij  ,,in ,,the ,,senate ,,of     
,,the ,,united ,,states  ,september #bh1
 #bjag ,mr4 ,cardin 7for himself1 ,mr4  
,blunt1 and ,mr4 ,nelson7 introduced the
 following bill2 which was read twice   
and referred to the ,committee on       
,finance  ,a ,,bill  ,to improve the    
understanding of1 and promote access to 
treatment for1 chronic kidney disease1  
and for other purposes4  #a4 ,short     
title ,this ,act may be cited as the    
,chronic ,kidney ,disease ,improvement  
in ,research and ,treatment ,act of     
#bjag4  #b4 ,table of contents ,the     
table of contents of this ,act is as    
follows3 ,sec4 #a4 ,short title4 ,sec4  
#b4 ,table of contents4 ,,title         
,i--,improving patient lives and quality
 of care through research and innovation
 ,sec4 #aja4 ,improving patient lives   
and quality of care through research and
 innovation4 ,sec4 #ajb4 ,enhancing care
 through new technologies4 ,sec4 #ajc4  
,understanding current utilization of   

palliative care services4 ,sec4 #ajd4   
,understanding the progression of kidney
 disease and treatment of kidney failure
 in minority populations4 ,,title       
,,ii--,empower patient decision making  
and choice ,sec4 #bja4 ,providing       
individuals with kidney failure access  
to managed care4 ,sec4 #bjb4 ,medigap   
coverage for beneficiaries with         
end-stage renal disease4 ,sec4 #bjc4    
,promoting access to home dialysis      
treatments4 ,,title ,,iii--,improving   
patient care and ensuring quality       
outcomes ,sec4 #cja4 ,maintain an       
economically stable dialysis            
infrastructure4 ,sec4 #cjb4 ,improve    
patient decision making and transparency
 by consolidating and modernizing       
quality programs4 ,sec4 #cjc4           
,increasing access to ,medicare kidney  
disease education benefit4 ,sec4 #cjd4  
,certification of new facilities4 ,sec4 
#cje4 ,improving access in underserved  
areas4  ,i ,improving patient lives and 
quality of care through research and    

innovation  #aja4 ,improving patient    
lives and quality of care through       
research and innovation  7a7 ,study ,the
 ,secretary of ,health and ,human       
,services 7in this section referred to  
as the ,secretary7 shall conduct a study
 on increasing kidney transplantation   
rates4 ,such study shall include an     
analysis of each of the following3  7#a7
 ,any disincentives in the payment      
systems under the ,medicare program     
under title ,,xviii of the ,social      
,security ,act that create barriers to  
kidney transplants and post-transplant  
care for beneficiaries with end-stage   
renal disease4  7#b7 ,the practices used
 by ,states with higher than average    
donation rates and whether those        
practices and policies could be         
successfully utilized in other ,states4 
7#c7 ,practices and policies that could 
increase deceased donation rates of     
minority populations4  7#d7 ,whether    
cultural and policy barriers exist to   
increasing living donation rates1       

including an examination of how to      
better facilitate chained donations4    
7#e7 ,other areas determined appropriate
 by the ,secretary4  7b7 ,report ,not   
later than #ah months after the date of 
the enactment of this ,act1 the         
,secretary shall submit to ,congress a  
report on the study conducted under     
subsection 7a71 together with such      
recommendations as the ,secretary       
determines to be appropriate4  #ajb4    
,enhancing care through new technologies
  7a7 ,agreement with ,national ,academy
 of ,sciences ,the ,secretary of ,health
 and ,human ,services shall seek to     
enter into an agreement with the        
,national ,academy of ,sciences within  
six months of the date of the enactment 
of this ,act under which the ,national  
,academy of ,sciences will conduct a    
study on the design of payments for     
renal dialysis services under the       
,medicare program under title ,,xviii of
 the ,social ,security ,act1 including  
an analysis of whether adjustments to   

such payments are needed to allow for   
the incorporation of new technologies   
and therapies4  7b7 ,contents ,in       
conducting the study under subsection   
7a71 the ,national ,academy of ,sciences
 shall evaluate the current payment     
system for renal dialysis services under
 the ,medicare program1 identify        
barriers to adopting innovative items1  
services1 and therapies1 and make       
recommendations as to how to eliminate  
such barriers4  #ajc4 ,understanding    
current utilization of palliative care  
services  7a7 ,study  7#a7 ,in general  
,the ,comptroller ,general of the       
,united ,states 7in this section        
referred to as the ,comptroller         
,general7 shall conduct a study on the  
utilization of palliative care in       
treating individuals with advanced      
kidney disease1 from stage #d through   
stage #e1 including individuals with    
kidney failure on dialysis through any  
progression of the disease4 ,such study 
shall include an analysis of--  7,a7 how

 palliative care can be utilized to     
improve the quality of life of those    
with kidney disease and facilitate care 
tailored to their individual goals and  
values2  7,b7 the successful use of     
palliative care in the care of patients 
with other chronic diseases and serious 
illnesses2  7,c7 the utilization of     
palliative care at any point in an      
illness1 including when used at the same
 time as curative treatment2 and  7,d7  
other areas determined appropriate by   
the ,comptroller ,general4  7#b7        
,definition of palliative care ,in this 
section1 the term palliative care means 
patient and family centered care that   
optimizes quality of life by            
anticipating1 preventing1 and treating  
suffering4 ,such term includes care that
 is furnished throughout the continuum  
of the illness that addresses physical1 
intellectual1 emotional1 social1 and    
spiritual needs and that facilitates    
patient autonomy1 access to information 
and choice4  7b7 ,report ,not later than

 #a year after the date of the enactment
 of this ,act1 the ,comptroller ,general
 shall submit to the ,congress a report 
on the study conducted under subsection 
7a71 together with such recommendations 
as the ,comptroller ,general determines 
to be appropriate4  #ajd4 ,understanding
 the progression of kidney disease and  
treatment of kidney failure in minority 
populations  7a7 ,study ,the ,secretary 
of ,health and ,human ,services 7in this
 section referred to as the ,secretary7 
shall conduct a study on--  7#a7 the    
social1 behavioral1 and biological      
factors leading to kidney disease2  7#b7
 efforts to slow the progression of     
kidney disease in minority populations  
that are disproportionately affected by 
such disease2 and  7#c7 treatment       
patterns associated with providing care1
 under the ,medicare program under title
 ,,xviii of the ,social ,security ,act1 
the ,medicaid program under title ,,xix 
of such ,act1 and through private health
 insurance1 to minority populations that

 are disproportionately affected by     
kidney failure4  7b7 ,report ,not later 
than #a year after the date of the      
enactment of this ,act1 the ,secretary  
shall submit to ,congress a report on   
the study conducted under subsection    
7a71 together with such recommendations 
as the ,secretary determines to be      
appropriate4  ,,ii ,empower patient     
decision making and choice  #bja4       
,providing individuals with kidney      
failure access to managed care  7a7     
,permanent extension of ,medicare       
,advantage ,,esrd special needs plans   
authority ,section #ahei7;f77#a7 of the 
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#bh7;f77#a77 is amended by       
inserting 1 in the case of a specialized
 ,,ma plan for special needs individuals
 who have not been determined to have   
end stage renal disease1 before for     
periods before ,january #a1 #bjai4  7b7 
,accelerated access to ,medicare        
,advantage ,section #agjjf7;a77#c7 of   
the #bast ,century ,cures ,act 7,public 

,law #aad-bee7 is amended by striking   
#bjba and inserting #bjbj4  7c7         
,accelerated ,med,p,a,c risk adjustment 
report ,section                         
#agjjf7;f77#b77;,a77i77,,ii7 of the     
#bast ,century ,cures ,act 7,public ,law
 #aad-bee7 is amended by striking #bjbj 
and inserting #bjai4  #bjb4 ,medigap    
coverage for beneficiaries with         
end-stage renal disease  7a7 ,guaranteed
 availability of medigap policies to all
 ,,esrd medicare beneficiaries  7#a7 ,in
 general ,section #ahhb7s7 of the       
,social ,security ,act 7#db ,u4,s4,c4   
#aciess7s77 is amended-- 7,a7 in        
paragraph 7#b7--  7i7 in subparagraph   
7,a71 by striking is #fe and inserting  
the following3 is-- 7i7 #fe years of age
 or older and is enrolled for benefits  
under part ,b2 or  7ii7 is entitled to  
benefits under #bbf;,a7b7 and is        
enrolled for benefits under part ,b4  2 
and  7ii7 in subparagraph 7,d71 in the  
matter preceding clause 7i71 by         
inserting 7or is entitled to benefits   

under #bbf;,a7b77 after is #fe years of 
age or older2 and  7,b7 in paragraph    
7#c77;,b7--  7i7 in clause 7ii71 by     
inserting 7or is entitled to benefits   
under #bbf;,a7b77 after is #fe years of 
age or older2 and  7ii7 in clause 7vi71 
by inserting 7or under #bbf;,a7b77 after
 at age #fe4  7#b7 ,effective date ,the 
amendments made by paragraph 7#a7 shall 
apply to ,medicare supplemental policies
 effective on or after ,january #a1     
#bjbj4  7b7 ,additional enrollment      
period for certain individuals  7#a7    
,one-time enrollment period  7,a7 ,in   
general ,in the case of an individual   
described in subparagraph 7,b71 the     
,secretary of ,health and ,human        
,services shall establish a one-time    
enrollment period during which such an  
individual may enroll in any ,medicare  
supplemental policy under section #ahhb 
of the ,social ,security ,act 7#db      
,u4,s4,c4 #aciess7 of the individual's  
choosing4  7,b7 ,enrollment period ,the 
enrollment period established under     

subparagraph 7,a7 shall begin on        
,january #a1 #bjbj1 and shall end ,june 
#cj1 #bjbj4  7#b7 ,individual described 
,an individual described in this        
paragraph is an individual who-- 7,a7 is
 entitled to hospital insurance benefits
 under part ,a of title ,,xviii of the  
,social ,security ,act under section    
#bbf;,a7b7 of such ,act 7#db ,u4,s4,c4  
#dbf-a72  7,b7 is enrolled for benefits 
under part ,b of such title ,,xviii2 and
  7,c7 would not1 but for the provisions
 of1 and amendments made by1 subsection 
7a7 be eligible for the guaranteed issue
 of a ,medicare supplemental policy     
under paragraph 7#b7 or 7#c7 of section 
#ahhb7s7 of such ,act 7#db ,u4,s4,c4    
#aciess7s774  #bjc4 ,promoting access to
 home dialysis treatments  7a7 ,in      
general ,section #ahha7;b77#c7 of the   
,social ,security ,act 7#db ,u4,s4,c4   
#acierr7b77#c77 is amended-- 7#a7 by    
redesignating subparagraphs 7,a7 and    
7,b7 as clauses 7i7 and 7ii71           
respectively2  7#b7 in clause 7ii71 as  

redesignated by subparagraph 7,a71 by   
striking on a comprehensive and         
inserting subject to subparagraph 7,b71 
on a comprehensive2  7#c7 by striking   
,with respect to and inserting 7,a7     
,with respect to2 and  7#d7 by adding at
 the end the following new subparagraph3
  7,b7 ,for purposes of subparagraph    
7,a77ii71 an individual determined to   
have end-stage renal disease receiving  
home dialysis may choose to receive the 
monthly end-stage renal disease-related 
visits furnished on or after ,january   
#a1 #bjah1 via telehealth if the        
individual receives a face-to-face      
visit1 without the use of telehealth1 at
 least once every three consecutive     
months4  4  7b7 ,originating site       
requirements  7#a7 ,in general ,section 
#ahcd7m7 of the ,social ,security ,act  
7#db ,u4,s4,c4 #aciem7m77 is amended--  
7,a7 in paragraph 7#d77;,c77ii71 by     
adding at the end the following new     
subclauses3  7,,ix7 ,a renal dialysis   
facility1 but only for purposes of      

section #ahha7;b77#c77;,b74  7,x7 ,the  
home of an individual1 but only for     
purposes of section #ahha7;b77#c77;,b74 
2 and  7,b7 by adding at the end the    
following new paragraph3  7#e7          
,treatment of home dialysis monthly     
,,esrd-related visit ,the geographic    
requirements described in paragraph     
7#d77;,c77i7 shall not apply with       
respect to telehealth services furnished
 on or after ,january #a1 #bjah1 for    
purposes of section #ahha7;b77#c77;,b71 
at an originating site described in     
subclause 7,,vi71 7,,ix71 or 7,x7 of    
paragraph 7#d77;,c77ii74  4  7#b7 ,no   
facility fee if originating site for    
home dialysis therapy is the home       
,section #ahcd7m77#b77;,b7 of the       
,social ,security 7#db ,u4,s4,c4        
#aciem7m77#b77;,b77 is amended-- 7,a7 by
 redesignating clauses 7i7 and 7ii7 as  
subclauses 7,i7 and 7,,ii71 and         
indenting appropriately2  7,b7 in       
subclause 7,,ii71 as redesignated by    
subparagraph 7,a71 by striking clause   

7i7 or this clause and inserting        
subclause 7,i7 or this subclause2  7,c7 
by striking site4--,with respect to and 
inserting  site4-- 7i7 ,in general      
,subject to clause 7ii71 with respect to
  2 and  7,d7 by adding at the end the  
following new clause3  7ii7 ,no facility
 fee if originating site for home       
dialysis therapy is the home ,no        
facility fee shall be paid under this   
subparagraph to an originating site     
described in paragraph                  
7#d77;,c77ii77,x74  4  7c7 ,conforming  
amendment ,section #ahha7;b77#a7 of the 
,social ,security ,act 7#db ,u4,s4,c4   
#acierr7b77#a77 is amended by striking  
paragraph 7#c77;,a7 and inserting       
paragraph 7#c77;,a77i74  7d7 ,exclusion 
from remuneration for purposes of       
applying civil monetary penalties  7#a7 
,in general ,section #aabh;,a7i77#f7 of 
the ,social ,security ,act 7#db         
,u4,s4,c4 #acbj;a-#g;a7i77#f77 is       
amended--  7,a7 in subparagraph         
7,h77iv71 by striking 2 or at the end2  

7,b7 in subparagraph 7,i71 by striking  
the period at the end and inserting 2   
or2 and  7,c7 by adding at the end the  
following new subparagraph3  7,j7 the   
provision of telehealth or remote       
patient monitoring technologies to      
individuals under title ,,xviii by a    
health care provider for the purpose of 
furnishing telehealth or remote patient 
monitoring services4  4  7#b7 ,effective
 date ,the amendments made by this      
subsection shall apply to services      
furnished on or after the date of the   
enactment of this ,act4  ,,iii          
,improving patient care and ensuring    
quality outcomes  #cja4 ,maintain an    
economically stable dialysis            
infrastructure  7a7 ,in general ,section
 #ahha7;b77#ad7 of the ,social ,security
 ,act 7#db ,u4,s4,c4 #acierr7b77#ad77 is
 amended-- 7#a7 in subparagraph 7,d71 in
 the matter preceding clause 7i71 by    
striking ,such system and inserting     
,subject to subparagraph 7,j71 such     
system2 and  7#b7 by adding at the end  

the following new subparagraph3  7,j7   
,for payment for renal dialysis services
 furnished on or after ,january #a1     
#bjah1 under the system under this      
paragraph--  7i7 the payment adjustment 
described in clause 7i7 of subparagraph 
7,d7-- 7,i7 shall not take into account 
comorbidities2 and  7,,ii7 shall only   
take into account age for purposes of   
distinguishing between individuals who  
are under #ah years of age and those who
 are #ah years of age and older but     
shall not include any other adjustment  
for age2  7ii7 the ,secretary shall     
reassess any adjustments related to     
patient weight under such clause2  7iii7
 the payment adjustment described in    
clause 7ii7 of such subparagraph shall  
not be included2  7iv7 the              
standardization factor described in the 
final rule published in the ,federal    
,register on ,november #h1 #bjab 7#gg   
,fed4 ,reg4 #fgdgj71 shall be           
established using the most currently    
available data 7and not historical data7

 and adjusted on an annual basis1 based 
on such available data1 to account for  
any change in utilization of drugs and  
any modification in adjustors applied   
under this paragraph2 and  7v7 take into
 account reasonable costs for           
determining the payment rate consistent 
with paragraph 7#b77;,b74  4  7b7       
,inclusion of network fee as an         
allowable cost ,section #ahha7;b77#ad7  
of the ,social ,security ,act 7#db      
,u4,s4,c4 #acierr7b77#ad771 as amended  
by subsection 7a71 is amended by adding 
at the end the following new            
subparagraph3  7,k7 ,not later than     
,january #a1 #bjah1 the ,secretary shall
 amend the ,,esrd facility cost report  
to include the per treatment network fee
 7as described in paragraph 7#g77 as an 
allowable cost or offset to revenue4  4 
#cjb4 ,improve patient decision making  
and transparency by consolidating and   
modernizing quality programs  7a7       
,measures ,section #ahha7;h77#b7 of the 
,social ,security ,act 7#db ,u4,s4,c4   

#acierr7h77#b77 is amended by adding at 
the end the following new subparagraphs3
  7,f7 ,weighting limitation ,no single 
measure specified by the ,secretary or  
individual measure within a composite   
measure so specified may be weighted    
less than #aj percent of the total      
performance score4  7,g7 ,statistically 
valid and reliable ,in specifying       
measures under subparagraph 7,a71 the   
,secretary shall only specify measures  
that have been shown to be statistically
 valid and reliable through testing4  4 
7b7 ,endorsement ,section               
#ahha7;h77#b77;,b7 of the ,social       
,security ,act 7#db ,u4,s4,c4           
#acierr7h77#b77;,b77 is amended-- 7#a7  
in clause 7ii71 by adding at the end the
 following new sentence3 ,the exception 
under the preceding sentence shall not  
apply to a measure that the entity with 
a contract under section #ahij7;a7 7or a
 similar entity7 considered but failed  
to endorse42 and  7#b7 by adding at the 
end the following new clause3  7iii7    

,composite measures ,clauses 7i7 and    
7ii7 shall apply to composite measures  
in the same manner as such clauses apply
 to individual measures4  4  7c7        
,requirements for dialysis facility     
compare star rating program ,section    
#ahha7;h77#f7 of the ,social ,security  
,act 7#db ,u4,s4,c4 #acierr7h77#f77 is  
amended by adding at the end the        
following new subparagraph3  7,e7       
,requirements for any dialysis facility 
compare star rating program ,to the     
extent that the ,secretary maintains a  
dialysis facility compare star rating   
program1 under such a program the       
,secretary--  7i7 shall assign stars    
using the same methodology and total    
performance score results from the      
quality incentive program under this    
subsection2  7ii7 shall determine the   
stars using the same methodology used   
under such quality incentive program2   
and  7iii7 shall not use a forced bell  
curve when determining the stars or     
rebaselining the stars4  4  7d7         

,hospitals required ,to provide         
information ,section #ahha of the       
,social ,security ,act 7#db ,u4,s4,c4   
#acierr7 is amended by adding at the end
 the following new subsection3  7i7     
,hospitals required ,to provide         
information  7#a7 ,in general ,the      
,secretary shall establish a process    
under which a hospital or a critical    
access hospital shall provide a renal   
dialysis facility with health and       
treatment information with respect to an
 individual who is discharged from the  
hospital or critical access hospital and
 who subsequently receives treatment at 
facility4  7#b7 ,elements ,under the    
process established under paragraph     
7#a7-- 7,a7 the request for the health  
information may be initiated by the     
individual prior to discharge or upon   
request by the renal dialysis facility  
after the patient is discharged2 and    
7,b7 the information must be provided to
 the facility within #g days of the     
request being made4  4  7e7 ,incentive  

payments ,section #ahha7;h77#a7 of the  
,social ,security ,act 7#db ,u4,s4,c4   
#acierr7h77#a77 is amended by adding at 
the end the following new subparagraph3 
7,d7 ,incentive payments  7i7 ,in       
general ,in the case of a provider of   
services or a renal dialysis facility   
that the ,secretary determines exceeds  
the attainment performance standards    
under paragraph 7#d7 with respect to a  
year1 the ,secretary may make a bonus   
payment to the provider or facility     
7pursuant to a process established by   
the ,secretary74  7ii7 ,funding ,the    
total amount of bonus payments under    
clause 7i7 in a year shall be equal to  
the total amount of reduced payments in 
a year under subparagraph 7,a74  7iii7  
,no effect in subsequent years ,the     
provisions of subparagraph 7,c7 shall   
apply to a bonus payment under this     
subparagraph in the same manner         
subparagraph 7,c7 applies to a reduction
 under such subparagraph4  4  7f7       
,effective date ,the amendments made by 

this section shall apply to items and   
services furnished on or after ,january 
#a1 #bjai4  #cjc4 ,increasing access to 
,medicare kidney disease education      
benefit  7a7 ,in general ,section       
#ahfa7;ggg7 of the ,social ,security    
,act 7#db ,u4,s4,c4 #aciex7ggg77 is     
amended-- 7#a7 in paragraph 7#a7--  7,a7
 in subparagraph 7,a71 by inserting or  
stage ,v after stage ,,iv2 and  7,b7 in 
subparagraph 7,b71 by inserting or of a 
physician assistant1 nurse practitioner1
 or clinical nurse specialist 7as       
defined in section #ahfa7;aa77#e77      
assisting in the treatment of the       
individual's kidney condition after     
kidney condition2 and  7#b7 in paragraph
 7#b7-- 7,a7 by striking subparagraph   
7,b72 and  7,b7 in subparagraph 7,a7--  
7i7 by striking 7,a7 after 7#b72  7ii7  
by striking and at the end of clause    
7i72  7iii7 by striking the period at   
the end of clause 7ii7 and inserting 2  
and2  7iv7 by redesignating clauses 7i7 
and 7ii7 as subparagraphs 7,a7 and 7,b71

 respectively2 and  7v7 by adding at the
 end the following3  7,c7 a renal       
dialysis facility subject to the        
requirements of section #ahha7;b77#a7   
with personnel who-- 7i7 provide the    
services described in paragraph 7#a72   
and  7ii7 is a physician 7as defined in 
subsection 7r77#a77 or a physician      
assistant1 nurse practitioner1 or       
clinical nurse specialist 7as defined in
 subsection 7aa77#e774  4  7b7 ,payment 
to renal dialysis facilities ,section   
#ahha7;b7 of the ,social ,security ,act 
7#db ,u4,s4,c4 #acierr7b77 is amended by
 adding at the end the following new    
paragraph3  7#ae7 ,for purposes of      
paragraph 7#ad71 the single payment for 
renal dialysis services under such      
paragraph shall not take into account   
the amount of payment for kidney disease
 education services 7as defined in      
section #ahfa7;ggg774 ,instead1 payment 
for such services shall be made to the  
renal dialysis facility on an           
assignment-related basis under section  

#ahdh4  4  7c7 ,effective date ,the     
amendments made by this section apply to
 kidney disease education services      
furnished on or after ,january #a1      
#bjah4  #cjd4 ,certification of new     
facilities  7a7 ,certification  7#a7 ,in
 general ,section #ahfe7;a77#a7 of the  
,social ,security ,act 7#db ,u4,s4,c4   
#acie;bb7a77#a77 is amended by striking 
or the conditions and requirements under
 section #ahha7;b74  7#b7 ,effective    
date ,the amendment made by paragraph   
7#a7 shall take effect on the date of   
enactment of this ,act and apply to a   
finding made on or after such date4  7b7
 ,timing for acceptance of requests from
 accreditation organizations ,not later 
than #f months after the date of the    
enactment of this ,act1 the ,secretary  
of ,health and ,human ,services shall   
accept a completed application from any 
national accreditation body for         
providers and facilities that provide   
services under #ahha7;b71 in accordance 
with section #ahfe7c77;,a774 ,any       

application received pursuant to the    
preceding sentence shall be deemed      
approved unless the ,secretary1 within  
#ij days after the date of the          
submission of the application to the    
,secretary1 either denies such request  
in writing or informs the applicant in  
writing with respect to any additional  
information that is needed in order to  
make a final determination with respect 
to the application4 ,if the ,secretary  
requests additional information pursuant
 to the preceding sentence and the      
applicant submits such information1 the 
application shall be deemed approved    
unless the ,secretary1 within #ij days  
of the date of receiving such           
information1 denies such request4  #cje4
 ,improving access in underserved areas 
7a7 ,definition of primary care services
 ,section #cca7;a77#c77;,d7 of the      
,public ,health ,service ,act 7#db      
,u4,s4,c4 #bed;d7a77#c77;,d77 is amended
 by inserting and includes renal        
dialysis services before the period at  

the end4  7b7 ,national health service  
corps scholarship program ,section      
#cch;,a7a77#b7 of the ,public ,health   
,service ,act 7#db ,u4,s4,c4            
#bedl7a77#b77 is amended by inserting 1 
including nephrology health             
professionals before the period at the  
end4  7c7 ,national health service corps
 loan repayment program ,section        
#cch;,b7a77#b7 of the ,public ,health   
,service ,act 7#db ,u4,s4,c4            
#bedl-#a7;a77#b77 is amended by         
inserting 1 including nephrology health 
professionals before the period at the  
end4