,,ii  #aaf? ,,congress  #a/ ,session    
,s4 #ajcg  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,april #d1 #bjai,mr4   
,b>rasso 7= himself & ,ms4 ,smi?7       
introduc$ ! foll[+ bill2 :i* 0 read     
twice & ref]r$ to ! ,committee on       
,f9ance  ,a ,,bill  ,to am5d title      
,,xviii ( ! ,social ,security ,act to   
mod]nize provisions relat+ to rural     
heal? cl9ics "u ,m$ic>e4  #a4 ,%ort     
title ,?is ,act may be cit$ z ! ,rural  
,heal? ,cl9ic ,mod]nization ,act (      
#bjai4  #b4 ,mod]niz+ physician1        
physician assi/ant1 & nurse practition] 
utilization requirem5ts  7a7 ,9 g5]al   
,section #ahfa7;aa7 ( ! ,social         
,security ,act 7#db ,u4,s4,c4           
#aciex7aa77 is am5d$-- 7#a7 9 p>agraph  
7#b77;,b71 by /rik+ has an arrangem5t & 
all t foll[s ?r\gh ! fir/ semicolon &   
ins]t+ meets ! requirem5ts describ$ 9   
p>agraph 7#h722 &  7#b7 by add+ at ! end
 ! foll[+ new p>agraph3  7#h7           
,requirem5ts = c]ta9 facilities describ$
 ,= purposes ( p>agraph 7#b77;,b71 )    

respect to a facility :i* is n a        
physician-direct$ cl9ic1 ! foll[+       
requirem5ts are describ$ 9 ?is p>agraph3
  7,a7 ,arrangem5t ,! facility has an   
arrangem5t consi/5t ) ! provisions (    
,/ate & local law relative to !         
practice1 p]=mance1 & deliv]y ( heal?   
s]vices1 ) "o or m physician assi/ants  
7z def9$ 9 p>agraph 7#e77;,a77 or "o or 
m nurse practition]s 7z def9$ 9 su*     
p>agraph74  7,b7 ,practice & ov]sight   
requirem5ts  7i7 ,9 g5]al ,subject to   
clause 7ii71 ! deliv]y ( heal? s]vices  
"u su* arrangem5t %all be 9 accordance )
 ,/ate law or ! ,/ate regulatory        
me*anism gov]n+ ! practice ( physician  
assi/ants or nurse practition]s4  7ii7  
,exception if no ,/ate laws or          
regulations applicable ,9 ! case :]e a  
,/ate does n h laws or regulations      
gov]n+ ! practice1 p]=mance1 & deliv]y (
 heal? s]vices by a physician assi/ant  
or nurse practition]1 ! ,secret>y %all  
adopt regulations = facilities locat$ 9 
su* ,/ate t provide = ! p]iodic review  

by physicians ( cov]$ s]vices furni%$ by
 physician assi/ants & nurse            
practition]s1 ! sup]vision & guidance by
 su* physicians ( physician assi/ants & 
nurse practition]s1 & ! prep>ation by   
su* physicians ( su* m$ical ord]s = c>e 
& treatm5t ( cl9ic pati5ts z is         
necess>y4 ,su* regulations %all also    
require facilities locat$ 9 su* a ,/ate 
to h arrangem5ts ) physicians = ref]ral 
( & consultation = pati5ts z ! facility 
deems necess>y & = advice & assi/ance 9 
! managem5t ( m$ical em]g5cies4  4  7b7 
,effective date ,! am5dm5ts made by ?is 
section %all take effect on ! date ( !  
enactm5t ( ?is ,act4  #c4 ,remov+       
outdat$ laboratory requirem5ts  7a7 ,9  
g5]al ,section #ahfa7;aa77#b77;,g7 ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#aciex7aa77#b77;,g77 is am5d$ by /rik+ 1
 includ+ cl9ical laboratory s]vices &   
all t foll[s ?r\gh additional diagno/ic 
s]vices & ins]t+ ! foll[+3 & has prompt 
access to cl9ical laboratory s]vices &  
additional diagno/ic s]vices4  7b7      

,effective date ,! am5dm5ts made by ?is 
section %all take effect on ! date ( !  
enactm5t ( ?is ,act4  #d4 ,all[+ rural  
heal? cl9ics ! flexibility to contract )
 physician assi/ants & nurse            
practition]s  7a7 ,9 g5]al ,section     
#ahfa7;aa7 ( ! ,social ,security ,act   
7#db ,u4,s4,c4 #aciex7aa771 9 ! fir/    
s5t5ce ( ! flu% matt] foll[+ p>agraph   
7#b71 is am5d$ by /rik+ 7iii7 employs a 
physician assi/ant or nurse practition]1
 & 7iv7 & ins]t+ & 7iii74  7b7          
,effective date ,! am5dm5t made by      
subsection 7a7 %all take effect on !    
date ( ! enactm5t ( ?is ,act4  #e4      
,all[+ rural heal? cl9ics to be ! di/ant
 site = a teleheal? visit  7a7 ,9 g5]al 
,section #ahcd7m7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #aciem7m77 is       
am5d$--  7#a7 9 ! fir/ s5t5ce ( p>agraph
 7#a7-- 7,a7 by /rik+ or a practition]  
7describ$ 9 section #ahdb7;b77#ah77;,c77
 & ins]t+ 1 a practition] 7describ$ 9   
section #ahdb7;b77#ah77;,c771 or a rural
 heal? cl9ic2 &  7,b7 by /rik+ or       

practition] & ins]t+ 1 practition]1 or  
rural heal? cl9ic2  7#b7 9 p>agraph     
7#b77;,a7--  7,a7 by /rik+ or           
practition] & ins]t+ practition]1 or    
rural heal? cl9ic2 &  7,b7 by /rik+ su* 
physician or practition] & ins]t+ su*   
physician1 practition]1 or rural heal?  
cl9ic2 &  7#c7 9 p>agraph 7#d77;,a71 by 
/rik+ or practition] & ins]t+           
practition]1 or rural heal? cl9ic4  7b7 
,effective date ,! am5dm5ts made by ?is 
section %all apply to s]vices furni%$ on
 or aft] ! date ( ! enactm5t ( ?is ,act4
  #f4 ,includ+ facilities locat$ 9 c]ta9
 areas  7a7 ,9 g5]al ,section #ahfa7;aa7
 ( ! ,social ,security ,act 7#db        
,u4,s4,c4 #aciex7aa77 is am5d$1 9 ! fir/
 s5t5ce ( ! flu% matt] foll[+ p>agraph  
7#b71 by ins]t+ or 9 an area t has be5  
designat$ by ! *ief executive (fic] ( ! 
,/ate & c]tifi$ by ! ,secret>y z rural  
aft] ,c5sus74  7b7 ,effective date ,!   
am5dm5t made by ?is section %all take   
effect on ! date ( ! enactm5t ( ?is     
,act4  #g4 ,increas+ reimbursem5t =     

rural heal? cl9ics ,section #ahcc7;f7 ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#aciel7f77 is am5d$--  7#a7 9 p>agraph  
7#a71 by /rik+ 1 & at ! end & ins]t+ a  
semicolon2  7#b7 9 p>agraph 7#b7--  7,a7
 by ins]t+ 7be=e #bjbj7 aft] 9 a        
subsequ5t ye>2 &  7,b7 by /rik+ ! p]iod 
at ! end & ins]t+ a semicolon2 &  7#c7  
by add+ at ! end ! foll[+ new p>agraphs3
  7#c7 9 #bjbj1 at #aje p] visit2  7#d7 
9 #bjba1 at #aaj p] visit2  7#e7 9      
#bjbb1 at #aae p] visit2 &  7#f7 9 a    
subsequ5t ye>1 at ! limit e/abli%$ "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