,i  #aahth ,,congress  #ast ,session    
,h4 ,r4 #bgac  ,,in ,,the ,,house ,,of  
,,representatives  ,april #ai1 #bjbc,mr4
 ,joyce of ,ohio 7for himself1 ,ms4     
,bonamici1 ,ms4 ,underwood1 ,mrs4       
,kiggans of ,virginia1 ,ms4 ,schakowsky1
 ,mr4 ,armstrong1 ,mr4 ,blumenauer1 ,mr4
 ,smith of ,nebraska1 ,mr4 ,grothman1   
,mr4 ,pappas1 and ,ms4 ,kuster7         
introduced the following bill2 which was
 referred to the ,committee on ,energy  
and ,commerce1 and in addition to the   
,committee on ,ways and ,means1 for a   
period to be subsequently determined by 
the ,speaker1 in each case for          
consideration of such provisions as fall
 within the jurisdiction of the         
committee concerned  ,a ,,bill  ,to     
amend titles ,,xviii and ,,xix of the   
,social ,security ,act to increase      
access to services provided by advanced 
practice registered nurses under the    
,medicare and ,medicaid programs1 and   
for other purposes4  #a4 ,short title   
,this ,act may be cited as the          

,improving ,care and ,access to ,nurses 
,act or the ,i ,,can ,act4  ,i ,removal 
of ,barriers to ,practice on ,nurse     
,practitioners  #aja4 ,expanding access 
to cardiac rehabilitation programs and  
pulmonary rehabilitation programs under 
,medicare program  7a7 ,cardiac         
rehabilitation programs ,section        
#ahfa7;eee7 of the ,social ,security    
,act 7#db ,u4,s4,c4 #aciex7eee77 is     
amended-- 7#a7 in paragraph 7#b7-- 7,a7 
in subparagraph 7,a77i71 by striking a  
physician's office and inserting the    
office of a physician 7as defined in    
subsection 7r77#a77 or the office of a  
nurse practitioner1 clinical nurse      
specialist1 or physician assistant 7as  
those terms are defined in subsection   
7aa77#e772 and  7,b7 in subparagraph    
7,c71 by inserting 7as defined in       
subsection 7r77#a771 nurse practitioner1
 clinical nurse specialist1 or physician
 assistant 7as those terms are defined  
in subsection 7aa77#e77 after physician2
  7#b7 in paragraph 7#c77;,a71 by       

striking physician-prescribed exercise  
and inserting exercise prescribed by a  
physician 7as defined in subsection     
7r77#a771 nurse practitioner1 clinical  
nurse specialist1 or physician assistant
 7as those terms are defined in         
subsection 7aa77#e772 and  7#c7 in      
paragraph 7#e71 by inserting 7as defined
 in subsection 7r77#a771 nurse          
practitioner1 clinical nurse specialist1
 or physician assistant 7as those terms 
are defined in subsection 7aa77#e771    
after physician4  7b7 ,pulmonary        
rehabilitation programs ,section        
#ahfa7;fff7 of the ,social ,security    
,act 7#db ,u4,s4,c4 #aciex7fff77 is     
amended-- 7#a7 in paragraph 7#b77;,a71  
by striking physician-prescribed        
exercise and inserting exercise         
prescribed by a physician 7as defined in
 subsection 7r77#a771 nurse             
practitioner1 clinical nurse specialist1
 or physician assistant 7as those terms 
are defined in subsection 7aa77#e772 and
  7#b7 in paragraph 7#c71 by inserting  

after physician the following3 7as      
defined in subsection 7r77#a771 nurse   
practitioner1 clinical nurse specialist1
 or physician assistant 7as those terms 
are defined in subsection 7aa77#e7714   
#ajb4 ,permitting nurse practitioners to
 satisfy medicare documentation         
requirement for coverage of certain     
shoes for individuals with diabetes     
,section #ahfa7s77#ab7 of the ,social   
,security ,act 7#db ,u4,s4,c4           
#aciex7s77#ab77 is amended-- 7#a7 in    
subparagraph 7,a71 by inserting 1 nurse 
practitioner1 or physician assistant    
after physician2 and  7#b7 in           
subparagraph 7,c71 by inserting 1 nurse 
practitioner1 or physician assistant    
after each occurrence of physician4     
#ajc4 ,improvements to the assignment of
 beneficiaries under the ,medicare      
shared savings program ,section         
#ahii7;c77#a7 of the ,social ,security  
,act 7#db ,u4,s4,c4 #acie;jjj7c77#a77 is
 amended-- 7#a7 in subparagraph 7,a71 by
 striking and at the end2  7#b7 in      

subparagraph 7,b71 by striking the      
period at the end and inserting 2 and2  
and  7#c7 by adding at the end the      
following new subparagraph3  7,c7 in the
 case of performance years beginning on 
or after ,january #a1 #bjbd1 primary    
care services provided under this title 
by an ,,aco professional described in   
subsection 7h77#a77;,b74  4  #ajd4      
,expanding the availability of medical  
nutrition therapy service ,medicare     
program ,section #ahfa7vv77#a7 of the   
,social ,security ,act 7#db ,u4,s4,c4   
#aciex7vv77#a77 is amended by inserting 
1 a nurse practitioner1 a clinical nurse
 specialist1 or a physician assistant   
7as such terms are defined in subsection
 7aa77#e77 before the period at the end4
  #aje4 ,preserving access to home      
infusion therapy  7a7 ,allowing         
applicable providers ,to establish home 
infusion therapy plans ,section         
#ahfa7;iii77#a77;,b7 of the ,social     
,security ,act 7#db ,u4,s4,c4           
#aciex7iii77#a77;,b77 is amended-- 7#a7 

by striking a physician 7as defined in  
subsection 7r77#a77 and inserting an    
applicable provider 7as defined in      
paragraph 7#c77;,a772 and  7#b7 by      
striking a physician 7as so defined7 and
 inserting an applicable provider 7as so
 defined74  7b7 ,conforming amendment   
,section #ahcd7u77#f7 of the ,social    
,security ,act 7#db ,u4,s4,c4           
#aciem7u77#f77 is amended by striking   
physician and inserting applicable      
provider 7as defined in section         
#ahfa7;iii77#c77;,a774  #ajf4           
,increasing access to hospice care      
services  7a7 ,in general ,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 a nurse  
practitioner or2  7#b7 in clause 7i71 in
 the matter following subclause 7,,ii71 
by inserting or nurse practitioner after
 physician and inserting 1 nurse        
practitioner's after physician's2 and   
7#c7 in clause 7ii71 by striking or     

physician and inserting 1 physician1 or 
nurse practitioner4  7b7 ,hospice care  
definition ,section #ahfa7;dd77#a77;,c7 
of the ,social ,security ,act 7#db      
,u4,s4,c4 #aciex7dd77#a77;,c77 is       
amended by adding or nurse practitioner 
after physician4  7c7 ,nurse            
practitioner billing ,not later than #ij
 days after the date of the enactment of
 this ,act1 the ,secretary of ,health   
and ,human ,services shall revise       
section #dah4cjd of title #db1 ,code of 
,federal ,regulations1 to allow nurse   
practitioners to bill for services not  
described in paragraph 7a7 of such      
section in the same manner as physicians
 may bill for such services in          
accordance with paragraph 7b7 of such   
section4 ,such revision shall provide   
that such services furnished by a nurse 
practitioner shall be payable at the    
percent of the physician fee schedule   
specified in section #ahcc7;a77#a77,o7  
of the ,social ,security ,act 7#db      
,u4,s4,c4 #aciel7a77#a77,o774  #ajg4    

,streamlining care delivery in skilled  
nursing facilities and nursing          
facilities2 ,authorizing ,medicare and  
,medicaid inpatient hospital patients to
 be under the care of a nurse           
practitioner  7a7 ,medicare  7#a7       
,certification of post-hospital extended
 care services ,section #ahad7;a77#b7 of
 the ,social ,security ,act 7#db        
,u4,s4,c4 #acie;f7a77#b77 is amended by 
striking 1 or a nurse practitioner1 and 
inserting or a nurse practitioner 7in   
accordance with ,state law71 or4  7#b7  
,certification authority for nurse      
practitioners ,section #ahad7;a77#c7 of 
the ,social ,security ,act 7#db         
,u4,s4,c4 #acie;f7a77#c77 is amended by 
inserting or nurse practitioner after   
physician the first place that it       
appears4  7#c7 ,supervision requirement 
in skilled nursing facility services    
,section #ahai7;b77#f77;,a7 of the      
,social ,security ,act 7#db ,u4,s4,c4   
#acie;i-#c7;b77#f77;,a77 is amended--   
7,a7 in the header1 by striking         

,physician supervision and inserting    
,supervision2 and  7,b7 by inserting or 
a nurse practitioner1 in accordance with
 ,state law after physician4  7#d7      
,administration of part ,b ,section     
#ahdb7;b77#b77;,c7 of the ,social       
,security ,act 7#db ,u4,s4,c4           
#acieu7b77#b77;,c77 is amended-- 7,a7 by
 inserting or a nurse practitioner after
 a physician2 and  7,b7 by striking or a
 nurse practitioner working in          
collaboration with that physician1 or   
both4  7#e7 ,provision of medical and   
other health services ,section          
#ahfa7s77#b77,k77ii7 of the ,social     
,security ,act 7#db ,u4,s4,c4           
#aciex7s77#b77,k77ii77 is amended by    
striking or clinical nurse specialist   
7as defined in subsection 7aa77#e77     
working in collaboration 7as defined in 
subsection 7aa77#f77 with a physician   
7as defined in subsection 7r77#a77 and  
inserting 7as defined in subsection     
7aa77#e77;,a771 or by a clinical nurse  
specialist 7as defined in subsection    

7aa77#e77;,b77 working in collaboration 
with a physician 7as defined in         
subsection 7r77#a7714  7#f7 ,privileges 
for nurse practitioners ,section #ahfa  
of the ,social ,security ,act 7#db      
,u4,s4,c4 #aciex7 is amended-- 7,a7 in  
subsection 7e77#d71 by inserting 7or    
nurse practitioner1 in accordance with  
,state law7 after physician2  7,b7 in   
subsection 7f77#a71 by inserting or     
nurse practitioner1 after physician2 and
  7,c7 in subsection 7ee77#b71 by       
inserting or nurse practitioner1 after  
physician each place that it appears4   
7b7 ,medicaid  7#a7 ,certification      
authority for nurse practitioners       
,section #aijb7;a77#dd7 of the ,social  
,security ,act 7#db ,u4,s4,c4           
#acif;a7a77#dd77 is amended to read as  
follows3  7#dd7 in each case for which  
payment for inpatient hospital services1
 skilled nursing facility services1     
services in an intermediate care        
facility described in section #aije7;d71
 or inpatient mental hospital services  

is made under the ,state plan-- 7,a7 a  
physician or nurse practitioner 7or1 in 
the case of skilled nursing facility    
services or intermediate care facility  
services1 a physician or nurse          
practitioner1 or a clinical nurse       
specialist who is not an employee of the
 facility but is working in             
collaboration with a physician7         
certifies at the time of admission1 or1 
if later1 the time the individual       
applies for medical assistance under the
 ,state plan 7and a physician or nurse  
practitioner1 or a physician assistant  
under the supervision of a physician1   
or1 in the case of skilled nursing      
facility services or intermediate care  
facility services1 a physician or nurse 
practitioner1 or a clinical nurse       
specialist who is not an employee of the
 facility but is working in             
collaboration with a physician1         
recertifies1 where such services are    
furnished over a period of time1 in such
 cases1 at least as often as required   

under section #aijc7;g77#f7 7or1 in the 
case of services that are services      
provided in an intermediate care        
facility1 every year71 and accompanied  
by such supporting material1 appropriate
 to the case involved1 as may be        
provided in regulations of the          
,secretary71 that such services are or  
were required to be given on an         
inpatient basis because the individual  
needs or needed such services1 and  7,b7
 such services were furnished under a   
plan established and periodically       
reviewed and evaluated by a physician or
 nurse practitioner1 or1 in the case of 
skilled nursing facility services or    
intermediate care facility services1 by 
a physician or nurse practitioner1 or a 
clinical nurse specialist who is not an 
employee of the facility but is working 
in collaboration with a physician2  4   
7#b7 ,nursing facility services         
supervision and clinical records        
,section #aiai7;b77#f77;,a7 of the      
,social ,security ,act 7#db ,u4,s4,c4   

#acifr7b77#f77;,a77 is amended to read  
as follows3  7,a7 require that the      
health care of every resident be        
provided under the supervision of a     
physician or nurse practitioner 7or1 at 
the option of a ,state1 under the       
supervision of a clinical nurse         
specialist or physician assistant who is
 not an employee of the facility but who
 is working in collaboration with a     
physician72  4  #ajh4 ,improving access 
to ,medicaid clinic services ,section   
#aije7;a77#i7 of the ,social ,security  
,act 7#db ,u4,s4,c4 #acif;d7a77#i77 is  
amended by adding or nurse practitioner 
after physician in both places that it  
appears4  ,,ii ,removal of ,barriers to 
,practice on ,certified ,registered     
,nurse ,anesthetists  #bja4 ,clarifying 
that certified registered nurse         
anesthetists can be reimbursed by       
,medicare for evaluation and management 
services ,section #ahfa7;bb77#a7 of the 
,social ,security ,act 7#db ,u4,s4,c4   
#aciex7bb77#a77 is amended by inserting 

1 including pre-anesthesia evaluation   
and management services1 after and      
related care4  #bjb4 ,revision of       
conditions of payment relating to       
services ordered and referred by        
certified registered nurse anesthetists 
,not later than #c months after the date
 of enactment of this ,act1 the         
,secretary of ,health and ,human        
,services shall revise section #daj4fi  
of title #db1 ,code of ,federal         
,regulations1 to clarify that1 for      
purposes of payment under part ,b of    
title ,,xviii of the ,social ,security  
,act-- 7#a7 certified registered nurse  
anesthetists are authorized to order1   
certify1 and refer services to the      
extent allowed under the law of the     
,state in which the services are        
furnished2 and  7#b7 payment shall be   
made under such part for such services  
so ordered1 certified1 or referred by   
certified registered nurse anesthetists4
  #bjc4 ,special payment rule for       
teaching student registered nurse       

anesthetists ,section #ahdh7;a77#f7 of  
the ,social ,security ,act 7#db         
,u4,s4,c4 #aciew-#d7;a77#f77 is amended 
in the matter preceding subparagraph    
7,a71 by inserting or student registered
 nurse anesthetists after physician     
residents4  #bjd4 ,removing unnecessary 
and costly supervision of certified     
registered nurse anesthetists ,section  
#ahfa7;bb77#b7 of the ,social ,security 
,act 7#db ,u4,s4,c4 #aciex7bb77#b77 is  
amended-- 7#a7 in the second sentence1  
by inserting 1 but may not require that 
certified registered nurse anesthetists 
provide services under the supervision  
of a physician after certification of   
nurse anesthetists2 and  7#b7 in the    
third sentence1 by inserting under the  
supervision of an anesthesiologist after
 an anesthesiologist assistant4  #bje4  
,,crna services as a ,medicaid-required 
benefit  7a7 ,in general ,section       
#aije7;a77#e7 of the ,social ,security  
,act 7#db ,u4,s4,c4 #acif;d7a77#e77 is  
amended-- 7#a7 by striking and 7,b7 and 

inserting 7,b72 and  7#b7 by inserting  
before the semicolon at the end the     
following3 1 and 7,c7 services furnished
 by a certified registered nurse        
anesthetist 7as defined in section      
#ahfa7;bb77#b771 which such certified   
registered nurse anesthetist is         
authorized to perform under ,state law  
7or the ,state regulatory mechanism as  
provided by ,state law74  7b7 ,payment  
,section #aijb7;a7 of the ,social       
,security ,act 7#db ,u4,s4,c4           
#acif;d7a77 is amended-- 7#a7 in        
paragraph 7#hf71 by striking and at the 
end2  7#b7 in paragraph 7#hg71 by       
striking the period and inserting 2 and2
 and  7#c7 by inserting after paragraph 
7#hg7 the following new paragraph3      
7#hh7 provide for payment for the       
services of a certified registered nurse
 anesthetist 7as defined in section     
#ahfa7;bb77#a77 in amounts no lower than
 the amounts1 using the same            
methodology1 used for payment for       
amounts under section                   

#ahcc7;a77#a77;,h74  4  ,,iii ,removal  
of ,barriers to ,practice on ,certified 
,nurse-,midwives  #cja4 ,improving      
access to training in maternity care    
7a7 ,medicare payments for supervision  
by certified nurse-,midwives ,paragraph 
7#a7 of section #ahfa7;gg7 of the       
,social ,security ,act 7#db ,u4,s4,c4   
#aciex7gg77 is amended to read as       
follows3  7#a7 ,the term certified      
nurse-midwife services means-- 7,a7 such
 services furnished by a certified      
nurse-midwife 7as defined in paragraph  
7#b772 and  7,b7 such services 7and such
 supplies and services furnished as an  
incident to the nurse-midwife's service7
 which-- 7i7 the certified nurse-midwife
 is legally authorized to perform under 
,state law 7or the ,state regulatory    
mechanism provided by ,state law7 as    
would otherwise be covered if furnished 
by a physician2  7ii7 are furnished     
under the supervision of a              
certified-nurse midwife by an intern or 
resident-in-training 7as described in   

subsection 7b77#f772  7iii7 would       
otherwise be described in subparagraph  
7,a7 if furnished by a certified        
nurse-midwife2 and  7iv7 would otherwise
 be covered if furnished under the      
supervision of a physician4  4  7b7     
,clarifying permissibility of using     
certain grants for clinical training by 
certified nurse-,midwives ,section      
#haa7;a77#a7 of the ,public ,health     
,service ,act 7#db ,u4,s4,c4            
#bif;j7a77#a77 is amended by inserting 1
 including clinical training1 after     
projects4  #cjb4 ,improving medicare    
patient access to home health services  
provided by certified nurse-midwives    
7a7 ,in general ,section #ahce7;a7 of   
the ,social ,security ,act 7#db         
,u4,s4,c4 #acien7a77 is amended-- 7#a7  
in paragraph 7#b7-- 7,a7 by inserting or
 a certified nurse-midwife 7as defined  
in section #ahfa7;gg771 after or a      
physician assistant 7as defined in      
section #ahfa7;aa77#e77 who is working  
in accordance with ,state law12 and     

7,b7 in subparagraph 7,a7-- 7i7 in each 
of clauses 7ii7 and 7iii71 by striking  
or a physician assistant 7as the case   
may be7 and inserting a physician       
assistant1 or a certified nurse-midwife 
7as the case may be72 and  7ii7 in      
clause 7iv71 by-- 7,i7 inserting or by a
 certified nurse-midwife 7as defined in 
section #ahfa7;gg77 after 7but in no    
case later than the date that is #f     
months after the date of the enactment  
of the ,,cares ,act72 and  7,,ii7 by    
striking 7as defined in section         
#ahfa7;gg772 and  7#b7 in the matter    
following paragraph 7#b71 by striking or
 physician assistant 7as the case may   
be7 and inserting physician assistant1  
or certified nurse-midwife 7as the case 
may be7 each place it appears4  7b7     
,conforming amendments ,section #ahie of
 the ,social ,security ,act 7#db        
,u4,s4,c4 #acie7;fff77 is amended-- 7#a7
 in subsection 7c77#a71 by inserting a  
certified nurse-midwife 7as defined in  
section #ahfa7;gg771 after clinical     

nurse specialist 7as those terms are    
defined in section #ahfa7;aa77#e7712 and
  7#b7 in subsection 7e77#a77;,a71 by   
striking a physician a nurse            
practitioner or clinical nurse          
specialist1 and inserting a physician1 a
 nurse practitioner1 a clinical nurse   
specialist1 a certified nurse-midwife14 
#cjc4 ,improving access to ,,dmepos for 
,medicare beneficiaries ,section        
#ahcd7;a7 of the ,social ,security ,act 
7#db ,u4,s4,c4 #aciem7a77 is amended--  
7#a7 in paragraph 7#a77;,e77ii7 by      
striking or a clinical nurse specialist 
7as those terms are defined in section  
#ahfa7;aa77#e77 and inserting 1 a       
clinical nurse specialist 7as those     
terms are defined in section            
#ahfa7;aa77#e771 or a certified         
nurse-midwife 7as defined in section    
#ahfa7;gg772 and  7#b7 in paragraph     
7#aa77;,b77ii7-- 7,a7 by striking or a  
clinical nurse specialist 7as those     
terms are defined in section            
#ahfa7;aa77#e77 and inserting a clinical

 nurse specialist 7as those terms are   
defined in section #ahfa 7aa77#e771 or a
 certified nurse-midwife 7as defined in 
#ahfa7;gg772 and  7,b7 by striking or   
specialist and inserting specialist1 or 
nurse-midwife4  #cjd4 ,technical changes
 to qualifications and conditions with  
respect to the services of certified    
nurse-midwives ,section #ahfa7;gg77#b7  
of the ,social ,security ,act 7#db      
,u4,s4,c4 #aciex7gg77#b77 is amended by 
striking 1 or has been certified by an  
organization recognized by the          
,secretary and inserting and has been   
certified by the ,american ,midwifery   
,certification ,board 7or a successor   
organization74  ,,iv ,improving ,federal
 ,health ,programs for ,all ,advanced   
,practice ,registered ,nurses  #dja4    
,revising the local coverage            
determination process under the         
,medicare program  7a7 ,in general      
,section #ahfb7l77#e7 of the ,social    
,security ,act 7#db ,u4,s4,c4           
#aciey7l77#e77 is amended-- 7#a7 in     

subparagraph 7,d71 by adding at the end 
the following new clauses3  7vi7        
,identification of any medical or       
scientific experts whose advice was     
obtained by such contractor during the  
development of such determination1      
whether or not such contractor relied on
 such advice in developing such         
determination4  7vii7 ,a hyperlink to   
any written communication between such  
contractor and another entity that such 
contractor relied on when developing    
such determination4  7viii7 ,a hyperlink
 to any rule1 guideline1 protocol1 or   
other criterion that such contractor    
relied on when developing such          
determination4  2 and  7#b7 by adding at
 the end the following new              
subparagraphs3  7,e7 ,prohibition on    
imposition of practitioner              
qualifications ,the ,secretary shall    
prohibit a ,medicare administrative     
contractor that develops a local        
coverage determination from imposing    
such determination on any coverage      

limitation with respect to the          
qualifications of a physician 7as       
defined in section #ahfa7r77 or a       
practitioner described in section       
#ahdb7;b77#ah77;,c7 who may furnish the 
item or service that is the subject of  
such determination4  7,f7 ,civil        
monetary penalty ,a ,medicare           
administrative contractor that develops 
a local coverage determination that     
fails to make information described in  
subparagraph 7,d7 available as required 
by the ,secretary under such            
subparagraph or comply with the         
prohibition under subparagraph 7,e7 is  
subject to a civil monetary penalty of  
not more than #aj1jjj for each such     
failure4 ,the provisions of section     
#aabh;,a 7other than subsections 7a7 and
 7b77 shall apply to a civil money      
penalty under the previous sentence in  
the same manner as such provisions apply
 to a penalty or proceeding under       
section #aabh;,a7a74  4  7b7 ,timing of 
review ,section #ahfi7;f77#b7 of the    

,social ,security ,act 7#db ,u4,s4,c4   
#acie;ff7f77#b77 is amended by adding at
 the end the following new subparagraph3
  7,d7 ,timing of review ,an aggrieved  
party may file a complaint described in 
subparagraph 7,a7 with respect to a     
local coverage determination on or after
 the date that such determination is    
posted1 in accordance with section      
#ahfb7l77#e77;,d71 on the ,internet     
website of the ,medicare administrative 
contractor making such determination1   
whether or not such determination has   
taken effect4  4  7c7 ,effective date   
,the amendments made by this section    
shall apply to local coverage           
determinations made available on the    
internet website of a ,medicare         
administrative contractor and on the    
,medicare internet website on or after  
the date of the enactment of this ,act4 
#djb4 ,locum tenens ,section            
#ahdb7;b77#f7 of the ,social ,security  
,act 7#db ,u4,s4,c4 #acieu7b77#f77 is   
amended-- 7#a7 by striking and 7,j7 and 

inserting 1 7,j72 and  7#b7 by adding 1 
and 7,k7 in the case of services        
furnished by a certified registered     
nurse anesthetist 7as defined in section
 #ahfa7;bb77#b771 nurse practitioner1 or
 clinical nurse specialist 7as defined  
in section #ahfa7;aa77#e771 or a        
certified nurse midwife 7as defined in  
section #ahfa7;gg77#b77 after 7as       
defined in section #ahhf7;d77#b77;,d774 
,v ,miscellaneous  #eja4 ,effective date
 ,the provisions of1 including          
amendments made by1 this ,act 7other    
than sections #ajc and #dja7 shall apply
 with respect to items and services     
furnished on or after the date that is  
#ij days after the date of the enactment
 of this ,act4 ,notwithstanding any     
other provision of law1 the ,secretary  
of ,health and ,human ,services shall   
implement such provisions1 including    
such amendments1 through interim final  
rule or subregulatory guidance if the   
,secretary determines such              
implementation to be necessary for      

purposes of complying with the preceding
 sentence or with any other effective   
date provided in this ,act4