,,ii #aahth ,,congress #ast ,session ,s4 #ahfi ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,june #g1 #bjbc,mr4 ,braun 7for himself1 ,ms4 ,hassan1 and ,mr4 ,kennedy7 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 and title ,,xxvii of the ,public ,health ,service ,act to ensure fair billing practice for items and services furnished by off-campus hospital locations1 to amend such title ,,xviii to provide for payments for graduate nursing education costs1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,site-based ,invoicing and ,transparency ,enhancement ,act or the ,,site ,act4 #b4 ,ensuring fair billing practice for items and services furnished by off-campus hospital locations 7a7 ,promoting ,medicare site-,neutral payments ,section #ahcc7t77#ba7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t77#ba77 is amended-- 7#a7 by redesignating subparagraph 7,e7 as subparagraph 7,g72 and 7#b7 by inserting after subparagraph 7,d7 the following new subparagraphs3 7,e7 ,sunset of certain exceptions ,the provisions of clauses 7ii7 and 7iv7 of subparagraph 7,b7 shall not apply with respect to applicable items and services furnished on or after ,january #a1 #bjbe4 7,f7 ,special payment rule for non-applicable items and services furnished at certain off-campus dedicated emergency departments 7i7 ,in general ,in the case of covered ,,opd services furnished by an applicable dedicated emergency department during #bjbe or a subsequent year1 the payment amount for such service that would otherwise be determined under this subsection 7without regard to the application of this subparagraph7 for such year shall be reduced by #cj percent4 7ii7 ,applicable dedicated emergency department ,in clause 7i71 the term applicable dedicated emergency department means a dedicated emergency department 7as defined in section #dhi4bd7;b7 of title #db of the ,code of ,federal ,regulations7 that-- 7,i7 is an off-campus outpatient department of a provider 7as defined in subparagraph 7,b772 and 7,,ii7 is located #f or fewer miles from another hospital1 critical access hospital1 or rural emergency hospital1 including the parent hospital of such emergency department4 4 7b7 ,ensuring separate ,n,p,is for off-,campus outpatient departments of a provider 7#a7 ,in general ,section #aagc7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acbj;d-#b7;b77 is amended by adding at the end the following new paragraph3 7#c7 ,ensuring separate ,n,p,is for off-campus outpatient departments of a provider ,the standards specified under paragraph 7#a7 shall ensure that1 not later than ,january #a1 #bjbe1 each off-campus outpatient department of a provider 7as defined in section #ahcc7t77#ba77;,b77 is assigned a separate unique health identifier from such provider4 4 7#b7 ,treatment of certain departments as subparts of a hospital ,not later than ,january #a1 #bjbe1 the ,secretary of ,health and ,human ,services shall revise sections #afb4djh and #afb4daj of title #de1 ,code of ,federal ,regulations1 to ensure that each off-campus outpatient department of a provider 7as defined in section #ahcc7t77#ba77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t77#ba77;,b777 is treated as a subpart 7as described in such sections7 of such provider and assigned a unique health identifier pursuant to section #aagc7;b77#c7 of such ,act 7as added by paragraph 7#a774 7c7 ,billing requirements for off-,campus outpatient departments of a provider 7#a7 ,medicare ,section #ahff7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7a77#a77 is amended-- 7,a7 in subparagraph 7,x71 by striking and at the end2 7,b7 in subparagraph 7,y77ii77,v71 by striking the period and inserting 1 and2 and 7,c7 by inserting after subparagraph 7,y7 the following new subparagraph3 7,z7 in the case of a hospital with an off-campus outpatient department of a provider 7as defined in section #ahcc7t77#ba77;,b771 with respect to items and services furnished at such department of a provider on or after ,january #a1 #bjbe1 to include in any claim form submitted under this title 7including under part ,c of this title7 for such items and services the unique health identifier established for such department of a provider pursuant to section #aagc7;b77#c74 4 7#b7 ,other providers ,part ,e of title ,,xxvii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;gg-#aca et seq47 is amended by adding at the end the following new section3 #bgii;,b-#aj4 ,billing requirements for off-campus departments of a provider or facility ,a health care provider or facility may not1 with respect to items and services furnished to an individual at an off-campus outpatient department of a provider 7as defined in section #ahcc7t77#ba77;,b7 of the ,social ,security ,act7 on or after ,january #a1 #bjbe1 submit a claim for such items and services to a group health plan or health insurance issuer1 and may not bill such an individual or hold such individual liable for such items and services1 unless such items and services are billed-- 7#a7 using the separate unique health identifier established for such department pursuant to section #aagc7;b77#c7 of such ,act2 and 7#b7 on a ,,hipaa ,x#ab #hcg,p transaction form or ,,cms #aejj form 7or a successor transaction or form74 4 7#c7 ,effective date ,the amendment made by paragraph 7#a7 shall apply with respect to claims submitted for items and services furnished on or after ,january #a1 #bjbe4 #c4 ,payments for graduate nursing education costs 7a7 ,in general ,title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq47 is amended by adding at the end the following new section3 #ahii;,c4 ,payments for graduate nursing education costs 7a7 ,in general ,the ,secretary shall provide for payments for qualified training costs in accordance with this section4 ,such payments shall be made from the ,federal ,supplementary ,medical ,insurance ,trust ,fund under section #ahda4 7b7 ,establishment of ,hub structure 7#a7 ,application ,an eligible hospital seeking to operate as a ,graduate ,nursing ,education ,hub 7in this section referred to as a ,hub7 shall submit an application to the ,secretary at such time1 in such manner1 and containing such information as the ,secretary may specify4 7#b7 ,selection of eligible hospitals to operate as ,hub 7,a7 ,establishment of regions ,the ,secretary shall establish regions for ,hubs based on hospital referral regions4 7,b7 ,selection of eligible hospitals ,for each hospital referral region1 the ,secretary shall select not more than one eligible hospital to operate as a ,hub4 7,c7 ,limitation ,an eligible hospital may not be selected to operate1 or participate as an eligible partner of1 more than one ,hub under this section4 7,d7 ,adjacent regions ,an eligible hospital may be selected to operate as a ,hub for one or more adjacent hospital referral regions if no other qualifying eligible hospital submits an application for such regions1 in which case the eligible hospital shall operate as a single ,hub for such regions4 7,e7 ,multiple applications ,if more than one eligible hospital submits an application to operate as a ,hub for a hospital referral region1 the ,secretary shall consider each application submitted1 giving special consideration to the following3 7i7 ,the application of the eligible hospital that includes the greatest number of applicable schools of nursing that have an advanced practice registered nurse education program in the region 7or in an adjacent region if an eligible hospital has not been selected to operate as a ,hub for such region and the eligible hospital is submitting an application to operate as a single ,hub for both regions74 7ii7 ,the application of the eligible hospital that includes the greatest number of advanced practice registered nurses that have graduated from participating applicable schools of nursing over the preceding #c years4 7c7 ,hub requirements 7#a7 ,contracts ,each ,hub selected pursuant to subsection 7b77#b7 must enter into a written agreement with each eligible partner of the ,hub that meets contents and terms1 as determined by the ,secretary1 and sets out1 at a minimum1 the following3 7,a7 ,partner ,obligations ,the obligations of the eligible partner with respect to the provision of qualified training4 7,b7 ,reimbursement ,the obligation of the ,hub to reimburse the eligible partner 7in a timely manner as the ,secretary may specify7 for the costs of qualified training for which payment is made under this section that are attributable to such partner4 7,c7 ,governance ,structure ,a governance structure that includes the ,hub and one or more applicable schools of nursing in the leadership and an oversight process that is developed and approved by the ,hub1 participating applicable schools of nursing1 and other ,hub partners1 in accordance with requirements established by the ,secretary4 7,d7 ,coordination ,the maintenance of an adequate system for coordination of clinical education sites and preceptors4 ,the ,secretary may specify standards for such system4 7,e7 ,preceptor training ,a system for the ,hub to provide at least #d hours of preceptor training to each preceptor each year4 7,f7 ,public health needs ,a process for taking into consideration local1 ,state1 and regional workforce needs to ensure public health4 7d7 ,payments 7#a7 ,amount of payment ,the amount of payment to a ,hub under this section for qualified training costs during a year shall be equal to the product of-- 7,a7 the annual per student payment amount determined under paragraph 7#b7 for the ,hub for the year2 and 7,b7 the total number of positions distributed to the ,hub under subsection 7f71 as determined by the ,secretary4 7#b7 ,determination of ,hub-specific annual per student payment amount ,the ,secretary shall determine1 for each ,hub1 an annual per student payment amount for each year 7beginning with #bjbf74 ,such amount shall be equal to the unadjusted per student amount determined under paragraph 7#c71 as adjusted for geographic variation in wages in a budget neutral manner1 as determined appropriate by the ,secretary4 7#c7 ,unadjusted per student amount ,the unadjusted per student amount determined under this paragraph for a year is equal to the product of-- 7,a7 #gej hours2 and 7,b7 the median hourly wage for a nurse practitioner in the ,united ,states1 according to the ,occupational ,employment and ,wage ,statistics of the ,bureau of ,labor ,statistics for the most recent year for which such data is available 7or an appropriate successor measure71 increased or decreased by the percentage change in the consumer price index for all urban consumers 7all items2 ,united ,states city average7 from ,june of the most recent year for which such data is available to the ,june preceding the year involved4 7#d7 ,permissible uses of payment ,a ,hub may use payments provided under this section only for payment of the costs of qualified training4 7e7 ,number of training positions available ,the maximum number of positions for which payment made be made under this section for a year shall be equal to-- 7#a7 for each of #bjbf and #bjbg1 #aj1jjj advanced practice registered nurse students2 7#b7 for each of #bjbh and #bjbi1 #ae1jjj advanced practice registered nurse students2 7#c7 for each of #bjcj and #bjca3 #bj1jjj advanced practice registered nurse students2 and 7#d7 for #bjcb and subsequent years1 the greater of-- 7,a7 #bj1jjj advanced practice registered nurse students2 or 7,b7 the number of advanced practice registered nurse students needed to ensure the ratio of such students to the number of beneficiaries under the program under this title1 the ,medicaid program under title ,,xix1 and the ,,chip program under title ,,xxi during the year is the same as such ratio for #bjca4 7f7 ,distribution of training positions 7#a7 ,in general 7,a7 ,distribution ,the ,secretary shall distribute the applicable percent 7as defined in subparagraph 7,b77 of the total number of positions available for distribution under subsection 7e7 for a year as follows3 7i7 ,each ,hub shall receive a minimum number of positions1 as determined by the ,secretary4 7ii7 ,any remaining positions available for distribution under this subparagraph shall be distributed to ,hubs based on the following factors3 7,i7 ,the number of advanced practice registered nurses that have graduated from participating applicable schools of nursing over the preceding #c years4 7,,ii7 ,the share of the relevant hospital referral region that is located in an area designated as a health professional shortage area under section #ccb7;a77#a77;,a7 of the ,public ,health ,service ,act1 as determined by the ,secretary4 7,,iii7 ,the share of the relevant hospital referral region that is located in a frontier ,state 7as defined in section #ahhf7;d77#c77;,e77iii77,,ii774 7,,iv7 ,the share of the relevant hospital referral region that is located in a rural area 7as defined in section #ahhf7;d77#b77;,d774 7,v7 ,other factors determined appropriate by the ,secretary4 7,b7 ,applicable percent defined ,for purposes of subparagraph 7,a71 the term applicable percent means-- 7i7 for #bjbf and #bjbg1 #ajj percent2 7ii7 for #bjbh and #bjbi1 #ie percent2 and 7iii7 for #bjcj and each subsequent year1 #ij percent4 7#b7 ,testing new training models 7,a7 ,in general ,the ,secretary shall distribute the applicable percent 7as defined in subparagraph 7,b77 of the total number of positions available for distribution under this subsection for a year to test new models of training advanced practice registered nurses and other health care workers or account for different workforce needs 7for example1 a shortage of certified nurse-midwives or community health workers74 7,b7 ,applicable percent defined ,for purposes of subparagraph 7,a71 the term applicable percent means-- 7i7 for #bjbf and #bjbg1 #j percent2 7ii7 for #bjbh and #bjbi1 #e percent2 and 7iii7 for #bjcj and each subsequent year1 #aj percent4 7#c7 ,redistribution ,the ,secretary shall develop a process for redistributing-- 7,a7 unused positions2 and 7,b7 positions from terminated or closed ,hubs4 7g7 ,miscellaneous 7#a7 ,waiver authority ,the ,secretary may waive such requirements of title ,,xi and this title as may be necessary to carry out this section4 7#b7 ,administration ,chapter #ce of title #dd1 ,united ,states ,code1 shall not apply to the implementation of this section4 7#c7 ,judicial review ,there shall be no administrative or judicial review under section #ahfi1 #ahgh1 or otherwise1 with respect to determinations made under subsection 7d7 or subsection 7f74 7#d7 ,no effect on other payments for medical education costs ,nothing in this section shall affect payments under subsection 7d77#e77;,b71 7h71 or 7l77#b77;,b7 of section #ahhf4 7#e7 ,implementation funding ,for purposes of carrying out this section1 there are appropriated1 out of amounts in the ,treasury not otherwise appropriated1 to the ,centers for ,medicare ,medicaid ,services ,program ,management ,account for fiscal year #bjbd1 #ajj1jjj1jjj1 to remain available until expended4 7#f7 ,supplement not supplant ,payments under this section in any given year shall supplement1 not supplant1 other ,federal funds that have been made available in the year for advanced practice registered nurse clinical education or training4 7h7 ,definitions ,in this section3 7#a7 ,advanced practice registered nurse ,the term advanced practice registered nurse includes the following3 7,a7 ,a clinical nurse specialist 7as defined in subsection 7aa77#e7 of section #ahfa74 7,b7 ,a nurse practitioner 7as defined in such subsection74 7,c7 ,a certified registered nurse anesthetist 7as defined in subsection 7bb77#b7 of such section74 7,d7 ,a certified nurse-midwife 7as defined in subsection 7gg77#b7 of such section74 7#b7 ,ambulatory care setting ,the term ambulatory care setting includes a ,federally qualified health center 7as defined in section #ahfa7;aa77#d771 a rural health clinic 7as defined in section #ahfa7;aa77#d771 a nurse-managed clinic1 an ambulatory practice1 a behavioral health clinic 7including a clinic certified as a certified community behavioral health clinic pursuant to section #bbc of the ,protecting ,access to ,medicare ,act of #bjad7 or other behavioral health setting 7as determined appropriate by the ,secretary71 a physician or practitioner office1 a school1 a skilled nursing facility or nursing facility 7as defined in section #aiai7;a771 a hospice program1 a long-term care facility1 and any other setting specified by the ,secretary4 7#c7 ,applicable school of nursing ,the term applicable school of nursing means an accredited school of nursing 7as defined in section #hja of the ,public ,health ,service ,act74 7#d7 ,eligible hospital ,the term eligible hospital means a hospital or a critical access hospital that has a written agreement described in subsection 7c77#a7 in place with-- 7,a7 at least two applicable schools of nursing 7or at least one applicable school of nursing if there is only one applicable school of nursing within the hospital referral region72 and 7,b7 at least one ambulatory care setting that is not owned or operated by a ,hub operated by the hospital or critical access hospital4 7#e7 ,eligible partner 7,a7 ,in general ,the term eligible partner means-- 7i7 an applicable school of nursing that has an advanced practice registered nurse education program2 7ii7 an entity or practitioner that is a participating provider under this title or a ,state plan under title ,,xix 7or a waiver of such plan72 and 7iii7 any other entity determined appropriate by the ,secretary4 7,b7 ,limitation ,an applicable school of nursing1 entity1 or practitioner described in subparagraph 7,a7 may not participate as an eligible partner of more than one ,hub under this section4 7#f7 ,qualified training 7,a7 ,in general ,the term qualified training means training-- 7i7 that provides an advanced practice registered nurse with the clinical skills necessary to provide primary care1 behavioral health care1 obstetric care1 preventive care1 transitional care1 chronic care management1 and other services appropriate for individuals entitled to1 or enrolled for1 benefits under part ,a1 or enrolled under part ,b2 and 7ii7 subject to subparagraph 7,b71 at least a third of which is provided in an ambulatory care setting that is not owned or operated by a ,hub4 7,b7 ,waiver of requirement for eligible hospitals located in rural or medically undeserved areas ,the ,secretary may waive the requirement under subparagraph 7,a77ii71 or reduce the threshold otherwise applicable under such subparagraph1 with respect to an eligible hospital that is located in a rural or medically underserved area4 4 7b7 ,exclusion of payments from calculation of fee-for-,service costs under ,medicare ,advantage ,section #ahec7;c77#a77;,d77i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bc7;c77#a77;,d77i77 is amended by striking and #ahhf7n7 and #ahhf7;h7 and inserting #ahhf7n71 #ahhf7;h71 and #ahii;,c4