I 

108TH CONGRESS 

1ST SESSION H. R. 2333

To amend title XVIII of the Social Security Act and the Public Health 

Service Act to improve outpatient health care for Medicare beneficiaries 

who reside in rural areas, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

JUNE 4, 2003

Mr. MORAN of Kansas (for himself, Mr. POMEROY, Mr. BEREUTER, Mr. 

OSBORNE, Mr. MCINTYRE, Mrs. EMERSON, Mr. PETERSON of Pennsylvania, Mr. WALDEN of Oregon, Mr. TOWNS, Mr. BERRY, Mr. KIND, Mr. 

TURNER of Texas, Mr. LEACH, Mr. ALEXANDER, Mr. MARSHALL, Mr. 

UDALL of New Mexico, Mr. EDWARDS, Mr. KING of Iowa, and Mr. 

NUNES) introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy 

and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL

To amend title XVIII of the Social Security Act and the 

Public Health Service Act to improve outpatient health 

care for Medicare beneficiaries who reside in rural areas, 

and for other purposes.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,
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1 SECTION 1. SHORT TITLE; AMENDMENTS TO SOCIAL SECU2 RITY ACT; TABLE OF CONTENTS. 

3 (a) SHORT TITLE.—This Act may be cited as the 

4 ‘‘Rural Provider Equity Act of 2003’’. 

5 (b) AMENDMENTS TO SOCIAL SECURITY ACT.—Ex6 cept as otherwise specifically provided, whenever in this 

7 Act an amendment is expressed in terms of an amendment 

8 to or repeal of a section or other provision, the reference 

9 shall be considered to be made to that section or other 

10 provision of the Social Security Act. 

11 (c) TABLE OF CONTENTS.—The table of contents of 

12 this Act is as follows:

Sec. 1. Short title; amendments to Social Security Act; table of contents. 

Sec. 2. Rural physician reimbursement improvements. 

Sec. 3. Physician assistant, nurse practitioner, and clinical nurse specialist improvements. 

Sec. 4. Rural health clinic improvements. 

Sec. 5. Permanent increase for home health services furnished in a rural area. 

Sec. 6. Rural community health center improvements. 

Sec. 7. Ensuring appropriate coverage of ambulance services under ambulance 

fee schedule. 

Sec. 8. Rural mental health care accessibility improvements. 

Sec. 9. Rural health services research improvements. 

Sec. 10. Exclusion for loan payments under National Health Service Corps loan 

repayment program.

13 SEC. 2. RURAL PHYSICIAN REIMBURSEMENT IMPROVE14 MENTS. 

15 (a) MEDICARE INCENTIVE PAYMENT PROGRAM IM16 PROVEMENTS.—

17 (1) PROCEDURES FOR SECRETARY, AND NOT

18 PHYSICIANS, TO DETERMINE WHEN BONUS PAY19 MENTS UNDER MEDICARE INCENTIVE PAYMENT PRO-
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1 GRAM SHOULD BE MADE.—Section 1833(m) (42 

2 U.S.C. 1395l(m)) is amended—

3 (A) by inserting ‘‘(1)’’ after ‘‘(m)’’; and 

4 (B) by adding at the end the following new 

5 paragraph: 

6 ‘‘(2) The Secretary shall establish procedures under 

7 which the Secretary, and not the physician furnishing the 

8 service, is responsible for determining when a payment is 

9 required to be made under paragraph (1).’’. 

10 (2) EDUCATIONAL PROGRAM REGARDING THE

11 MEDICARE INCENTIVE PAYMENT PROGRAM.—The 

12 Secretary of Health and Human Services shall es13 tablish and implement an ongoing educational pro14 gram to provide education to physicians under the 

15 medicare program on the medicare incentive pay16 ment program under section 1833(m) of the Social 

17 Security Act (42 U.S.C. 1395l(m)). 

18 (3) ONGOING STUDY AND ANNUAL REPORT ON

19 THE MEDICARE INCENTIVE PAYMENT PROGRAM.—

20 (A) ONGOING STUDY.—The Secretary of 

21 Health and Human Services shall conduct an 

22 ongoing study on the medicare incentive pay23 ment program under section 1833(m) of the 

24 Social Security Act (42 U.S.C. 1395l(m)). Such 

25 study shall focus on whether such program in-
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1 creases the access of medicare beneficiaries who 

2 reside in an area that is designated (under sec3 tion 332(a)(1)(A) of the Public Health Service 

4 Act (42 U.S.C. 254e(a)(1)(A))) as a health pro5 fessional shortage area to physicians’ services 

6 under the medicare program. 

7 (B) ANNUAL REPORTS.—Not later than 1 

8 year after the date of enactment of this Act, 

9 and annually thereafter, the Secretary of 

10 Health and Human Services shall submit to 

11 Congress a report on the study conducted under 

12 subparagraph (A), together with recommenda13 tions for such legislation and administrative ac14 tions as the Secretary considers appropriate. 

15 (b) PHYSICIAN FEE SCHEDULE WAGE INDEX REVI16 SION.—Section 1848(e)(1) (42 U.S.C. 1395w–4(e)(1)) is 

17 amended—

18 (1) in subparagraph (A), by striking ‘‘subpara19 graphs (B) and (C)’’ and inserting ‘‘subparagraphs 

20 (B), (C), and (E)’’; and 

21 (2) by adding at the end the following new sub22 paragraph: 

23 ‘‘(E) FLOOR FOR WORK GEOGRAPHIC INDI24 CES.—Notwithstanding the work geographic 

25 index otherwise calculated under subparagraph
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1 (A)(iii), in no case may the work geographic 

2 index applied for payment under this section be 

3 less than—

4 ‘‘(i) 0.976 for services furnished dur5 ing 2004; 

6 ‘‘(ii) 0.987 for services furnished dur7 ing 2005; 

8 ‘‘(iii) 0.995 for services furnished dur9 ing 2006; and 

10 ‘‘(iv) 1.000 for services furnished dur11 ing 2007 and subsequent years.’’. 

12 SEC. 3. PHYSICIAN ASSISTANT, NURSE PRACTITIONER, AND 

13 CLINICAL NURSE SPECIALIST IMPROVE14 MENTS. 

15 (a) BROADENING MEDICARE BENEFICIARIES ACCESS

16 TO HOME HEALTH SERVICES AND HOSPICE CARE.—Sec17 tion 1861(r) (42 U.S.C. 1395f(x)) is amended by adding 

18 at the end the following new sentences: ‘‘For purposes of 

19 sections 1814(a)(2)(C), 1814(a)(7)(B), 1835(a)(2)(A), 

20 1861(m), 1861(dd), and 1895(c)(1), the term ‘physician’ 

21 includes a nurse practitioner, a clinical nurse specialist, 

22 and a physician assistant (as such terms are defined in 

23 subsection (aa)(5)) who does not have a direct or indirect 

24 employment relationship with the home health agency or 

25 hospice program (as the case may be), and is legally au-
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1 thorized to perform the services of a nurse practitioner, 

2 a clinical nurse specialist, or a physician assistant (as the 

3 case may be) in the jurisdiction in which the services are 

4 performed. For purposes of the preceding sentence, the 

5 provisions of section 1833(a)(1)(O) shall continue to apply 

6 with respect to amounts paid for services furnished by 

7 such a nurse practitioner, a clinical nurse specialist, and 

8 a physician assistant.’’. 

9 (b) SKILLED NURSING FACILITIES.—Section 

10 1819(b)(6) (42 U.S.C. 1395i–3(b)(6)) is amended—

11 (1) in the paragraph heading, by inserting ‘‘OR

12 NURSE PRACTITIONER’’ after ‘‘PHYSICIAN’’; and 

13 (2) in subparagraph (A), by inserting ‘‘or nurse 

14 practitioner, including approving in writing a rec15 ommendation that an individual be admitted to a 

16 skilled nursing facility, admitting an individual to a 

17 skilled nursing facility, and performing the initial 

18 admitting assessment and all visits thereafter’’ be19 fore the semicolon. 

20 (c) EFFECTIVE DATE.—The amendments made by 

21 this section shall take effect on January 1, 2004. 

22 SEC. 4. RURAL HEALTH CLINIC IMPROVEMENTS. 

23 (a) IMPROVEMENT IN RURAL HEALTH CLINIC REIM24 BURSEMENT UNDER MEDICARE.—
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1 (1) IN GENERAL.—Section 1833(f) (42 U.S.C. 

2 1395l(f)) is amended—

3 (A) in paragraph (1), by striking ‘‘, and’’ 

4 at the end and inserting a semicolon; 

5 (B) in paragraph (2)—

6 (i) by striking ‘‘in a subsequent year’’ 

7 and inserting ‘‘in 1989 through 2002’’; 

8 and

9 (ii) by striking the period at the end 

10 and inserting a semicolon; and 

11 (C) by adding at the end the following new 

12 paragraphs: 

13 ‘‘(3) in 2003, at $82 per visit; and 

14 ‘‘(4) in a subsequent year, at the limit estab15 lished under this subsection for the previous year in16 creased by the percentage increase in the MEI (as 

17 so defined) applicable to primary care services (as so 

18 defined) furnished as of the first day of that year.’’. 

19 (2) EFFECTIVE DATE.—The amendments made 

20 by paragraph (1) shall apply to services furnished on 

21 or after January 1, 2003. 

22 (b) EXCLUSION OF CERTAIN RURAL HEALTH CLINIC

23 AND FEDERALLY QUALIFIED HEALTH CENTER SERVICES

24 FROM THE MEDICARE PROSPECTIVE PAYMENT SYSTEM

25 FOR SKILLED NURSING FACILITIES.—
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1 (1) IN GENERAL.—Section 1888(e)(2)(A) (42 

2 U.S.C. 1395yy(e)(2)(A)) is amended—

3 (A) in clause (i)(II), by striking ‘‘clauses 

4 (ii) and (iii)’’ and inserting ‘‘clauses (ii), (iii), 

5 and (iv)’’; and 

6 (B) by adding at the end the following new 

7 clause: 

8 ‘‘(iv) EXCLUSION OF CERTAIN RURAL

9 HEALTH CLINIC AND FEDERALLY QUALI10 FIED HEALTH CENTER SERVICES.—Serv11 ices described in this clause are—

12 ‘‘(I) rural health clinic services 

13 (as defined in paragraph (1) of sec14 tion 1861(aa)); and 

15 ‘‘(II) Federally qualified health 

16 center services (as defined in para17 graph (3) of such section); 

18 that would be described in clause (ii) if 

19 such services were not furnished by an in20 dividual affiliated with a rural health clinic 

21 or a Federally qualified health center.’’. 

22 (2) EFFECTIVE DATE.—The amendments made 

23 by paragraph (1) shall apply to services furnished on 

24 or after January 1, 2004. 
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1 SEC. 5. PERMANENT INCREASE FOR HOME HEALTH SERV2 ICES FURNISHED IN A RURAL AREA. 

3 Section 1895 (42 U.S.C. 1395fff) is amended by add4 ing at the end the following new subsection: 

5 ‘‘(f) INCREASE IN PAYMENT FOR SERVICES FUR6 NISHED IN A RURAL AREA.—

7 ‘‘(1) IN GENERAL.—In the case of home health 

8 services furnished in a rural area (as defined in sec9 tion 1886(d)(2)(D)) on or after April 1, 2003, the 

10 Secretary shall increase the payment amount other11 wise made under this section for such services by 10 

12 percent. 

13 ‘‘(2) WAIVER OF BUDGET NEUTRALITY.—The 

14 Secretary shall not reduce the standard prospective 

15 payment amount (or amounts) under this section ap16 plicable to home health services furnished during a 

17 period to offset the increase in payments resulting 

18 from the application of paragraph (1).’’. 

19 SEC. 6. RURAL COMMUNITY HEALTH CENTER IMPROVE20 MENTS. 

21 (a) DELIVERY OF MEDICARE-COVERED PRIMARY

22 AND PREVENTIVE SERVICES AT FEDERALLY QUALIFIED

23 HEALTH CENTERS.—

24 (1) COVERAGE OF MEDICARE-COVERED AMBU25 LATORY SERVICES BY FQHCS.—Section 1861(aa)(3)
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1 (42 U.S.C. 1395x(aa)(3)) is amended to read as fol2 lows: 

3 ‘‘(3) The term ‘Federally qualified health center serv4 ices’ means—

5 ‘‘(A) services of the type described in subpara6 graphs (A) through (C) of paragraph (1), and such 

7 other services furnished by a Federally qualified 

8 health center for which payment may otherwise be 

9 made under this title if such services were furnished 

10 by a health care provider or health care professional 

11 other than a Federally qualified health center; and 

12 ‘‘(B) preventive primary health services that a 

13 center is required to provide under section 330 of 

14 the Public Health Service Act, 

15 when furnished to an individual as a patient of a Federally 

16 qualified health center and such services when provided 

17 by a health care provider or health care professional em18 ployed by or under contract with a Federally qualified 

19 health center shall be treated as billable visits for purposes 

20 of payment to the Federally qualified health center.’’. 

21 (2) ENSURING FQHC REIMBURSEMENT UNDER

22 HOSPITAL AND SKILLED NURSING FACILITY PRO23 SPECTIVE PAYMENT SYSTEMS.—Section 1862(a)(14) 

24 (42 U.S.C. 1395y(a)) is amended by inserting ‘‘Fed-
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1 erally qualified health center services,’’ after ‘‘quali2 fied psychologist services,’’. 

3 (3) TECHNICAL CORRECTIONS.—Clauses (i) and 

4 (ii)(II) of section 1861(aa)(4)(A) (42 U.S.C. 

5 1395x(aa)(4)(A)) are each amended by striking 

6 ‘‘(other than subsection (h))’’. 

7 (4) EFFECTIVE DATES.—The amendments 

8 made—

9 (A) by paragraphs (1) and (2) shall apply 

10 to services furnished on or after January 1, 

11 2004; and 

12 (B) by paragraph (3) shall take effect on 

13 the date of enactment of this Act. 

14 (b) PROVIDING SAFE HARBOR FOR CERTAIN COL15 LABORATIVE EFFORTS THAT BENEFIT MEDICALLY UN16 DERSERVED POPULATIONS.—

17 (1) IN GENERAL.—Section 1128B(b)(3) (42 

18 U.S.C. 1320a–7(b)(3)) is amended—

19 (A) in subparagraph (E), by striking 

20 ‘‘and’’ after the semicolon at the end; 

21 (B) in subparagraph (F), by striking the 

22 period at the end and inserting ‘‘; and’’; and 

23 (C) by adding at the end the following new 

24 subparagraph: 
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1 ‘‘(G) any remuneration between a public or 

2 nonprofit private health center entity described 

3 under clause (i) or (ii) of section 1905(l)(2)(B) 

4 and any individual or entity providing goods, 

5 items, services, donations or loans, or a com6 bination thereof, to such health center entity 

7 pursuant to a contract, lease, grant, loan, or 

8 other agreement, if such agreement contributes 

9 to the ability of the health center entity to 

10 maintain or increase the availability, or enhance 

11 the quality, of services provided to a medically 

12 underserved population served by the health 

13 center entity.’’. 

14 (2) RULEMAKING FOR EXCEPTION FOR HEALTH

15 CENTER ENTITY ARRANGEMENTS.—

16 (A) ESTABLISHMENT.—

17 (i) IN GENERAL.—The Secretary of 

18 Health and Human Services (in this para19 graph referred to as the ‘‘Secretary’’) shall 

20 establish, on an expedited basis, standards 

21 relating to the exception described in sec22 tion 1128B(b)(3)(G) of the Social Security 

23 Act, as added by paragraph (1), for health 

24 center entity arrangements to the 

25 antikickback penalties. 
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1 (ii) FACTORS TO CONSIDER.—The 

2 Secretary shall consider the following fac3 tors, among others, in establishing stand4 ards relating to the exception for health 

5 center entity arrangements under clause 

6 (i): 

7 (I) Whether the arrangement be8 tween the health center entity and the 

9 other party results in savings of Fed10 eral grant funds or increased revenues 

11 to the health center entity. 

12 (II) Whether the arrangement 

13 between the health center entity and 

14 the other party restricts or limits a 

15 patient’s freedom of choice. 

16 (III) Whether the arrangement 

17 between the health center entity and 

18 the other party protects a health care 

19 professional’s independent medical 

20 judgment regarding medically appro21 priate treatment. 

22 The Secretary may also include other 

23 standards and criteria that are consistent 

24 with the intent of Congress in enacting the 

25 exception established under this section. 
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1 (B) INTERIM FINAL EFFECT.—No later 

2 than 180 days after the date of enactment of 

3 this Act, the Secretary shall publish a rule in 

4 the Federal Register consistent with the factors 

5 under subparagraph (A)(ii). Such rule shall be 

6 effective and final immediately on an interim 

7 basis, subject to such change and revision, after 

8 public notice and opportunity (for a period of 

9 not more than 60 days) for public comment, as 

10 is consistent with this paragraph. 

11 SEC. 7. ENSURING APPROPRIATE COVERAGE OF AMBU12 LANCE SERVICES UNDER AMBULANCE FEE 

13 SCHEDULE. 

14 (a) AIR AMBULANCE SERVICE.—

15 (1) COVERAGE.—Section 1834(l) (42 U.S.C. 

16 1395m(l)) is amended—

17 (A) by redesignating paragraph (8), as 

18 added by section 221(a) of Medicare, Medicaid, 

19 and SCHIP Benefits Improvement and Protec20 tion Act of 2000 (114 Stat. 2763A–486), as en21 acted into law by section 1(a)(6) of Public Law 

22 106–554, as paragraph (9); and 

23 (B) by adding at the end the following new 

24 paragraph:
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1 ‘‘(10) ENSURING APPROPRIATE COVERAGE OF

2 AIR AMBULANCE SERVICES.—

3 ‘‘(A) IN GENERAL.—The regulations de4 scribed in section 1861(s)(7) shall ensure that 

5 air ambulance services (as defined in subpara6 graph (C)) are reimbursed under this sub7 section at the air ambulance rate if the air am8 bulance service— 

9 ‘‘(i) is medically necessary based on 

10 the health condition of the individual being 

11 transported at or immediately prior to the 

12 time of the transport; and 

13 ‘‘(ii) complies with equipment and 

14 crew requirements established by the Sec15 retary. 

16 ‘‘(B) MEDICALLY NECESSARY.—An air 

17 ambulance service shall be considered to be 

18 medically necessary for purposes of subpara19 graph (A)(i) if such service is requested—

20 ‘‘(i) by a physician or a hospital in ac21 cordance with the physician’s or hospital’s 

22 responsibilities under section 1867 (com23 monly known as the ‘Emergency Medical 

24 Treatment and Active Labor Act’); 
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1 ‘‘(ii) as a result of a protocol estab2 lished by a State or regional emergency 

3 medical service (EMS) agency; 

4 ‘‘(iii) by a physician, nurse practi5 tioner, physician assistant, registered 

6 nurse, or emergency medical responder 

7 who reasonably determines or certifies that 

8 the patient’s condition is such that the 

9 time needed to transport the individual by 

10 land or the lack of an appropriate ground 

11 ambulance, significantly increases the med12 ical risks for the individual; or 

13 ‘‘(iv) by a Federal or State agency to 

14 relocate patients following a natural dis15 aster, an act of war, or a terrorist attack. 

16 ‘‘(C) AIR AMBULANCE SERVICES DE17 FINED.—For purposes of this paragraph, the 

18 term ‘air ambulance service’ means fixed wing 

19 and rotary wing air ambulance services.’’. 

20 (2) CONFORMING AMENDMENT.—Section 

21 1861(s)(7) (42 U.S.C. 1395x(s)(7)) is amended by 

22 inserting ‘‘, subject to section 1834(l)(10),’’ after 

23 ‘‘but’’. 

24 (b) GROUND AMBULANCE SERVICE.—

25 (1) PAYMENT RATES.—
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1 (A) IN GENERAL.—Section 1834(l)(3) (42 

2 U.S.C. 1395m(l)(3)) is amended to read as fol3 lows: 

4 ‘‘(3) PAYMENT RATES.—

5 ‘‘(A) IN GENERAL.—Subject to any adjust6 ment under subparagraph (B) and paragraph 

7 (9) and the full payment of a national mileage 

8 rate pursuant to paragraph (2)(E), in estab9 lishing such fee schedule, the following rules 

10 shall apply: 

11 ‘‘(i) PAYMENT RATES IN 2003.—

12 ‘‘(I) GROUND AMBULANCE SERV13 ICES.—In the case of ground ambu14 lance services furnished under this 

15 part in 2003, the Secretary shall set 

16 the payment rates under the fee 

17 schedule for such services at a rate 

18 based on the average costs (as deter19 mined by the Secretary on the basis of 

20 the most recent and reliable informa21 tion available) incurred by full cost 

22 ambulance suppliers in providing non23 emergency basic life support ambu24 lance services covered under this title, 

25 with adjustments to the rates for 
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1 other ground ambulance service levels 

2 to be determined based on the rule es3 tablished under paragraph (1). For 

4 the purposes of the preceding sen5 tence, the term ‘full cost ambulance 

6 supplier’ means a supplier for which 

7 volunteers or other unpaid staff com8 prise less than 20 percent of the sup9 plier’s total staff and which receives 

10 less than 20 percent of space and 

11 other capital assets free of charge. 

12 ‘‘(II) OTHER AMBULANCE SERV13 ICES.—In the case of ambulance serv14 ices not described in subclause (I) 

15 that are furnished under this part in 

16 2003, the Secretary shall set the pay17 ment rates under the fee schedule for 

18 such services based on the rule estab19 lished under paragraph (1). 

20 ‘‘(ii) PAYMENT RATES IN SUBSE21 QUENT YEARS FOR ALL AMBULANCE SERV22 ICES.—In the case of any ambulance serv23 ice furnished under this part in 2004 or 

24 any subsequent year, the Secretary shall 

25 set the payment rates under the fee sched-
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1 ule for such service at amounts equal to 

2 the payment rate under the fee schedule 

3 for that service furnished during the pre4 vious year, increased by the percentage in5 crease in the Consumer Price Index for all 

6 urban consumers (United States city aver7 age) for the 12-month period ending with 

8 June of the previous year. 

9 ‘‘(B) ADJUSTMENT IN RURAL RATES.—For 

10 years beginning with 2004, the Secretary, after 

11 taking into consideration the recommendations 

12 contained in the report submitted under section 

13 221(b)(3) the Medicare, Medicaid, and SCHIP 

14 Benefits Improvements and Protection Act of 

15 2000, shall adjust the fee schedule payment 

16 rates that would otherwise apply under this 

17 subsection for ambulance services provided in 

18 low density rural areas based on the increased 

19 cost (if any) of providing such services in such 

20 areas.’’. 

21 (B) CONFORMING AMENDMENT.—Section 

22 221(c) of the Medicare, Medicaid, and SCHIP 

23 Benefits Improvement and Protection Act of 

24 2000 (114 Stat. 2763A–487), as enacted into
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1 law by section 1(a)(6) of Public Law 106–554, 

2 is repealed. 

3 (2) USE OF MEDICAL CONDITIONS FOR CODING

4 AMBULANCE SERVICES.—Section 1834(l)(7) (42 

5 U.S.C. 1395m(l)(7)) is amended to read as follows: 

6 ‘‘(7) CODING SYSTEM.—

7 ‘‘(A) IN GENERAL.—The Secretary shall, 

8 in accordance with section 1173(c)(1)(B), es9 tablish a system or systems for the coding of 

10 claims for ambulance services for which pay11 ment is made under this subsection, including a 

12 code set specifying the medical condition of the 

13 individual who is transported and the level of 

14 service that is appropriate for the transpor15 tation of an individual with that medical condi16 tion. 

17 ‘‘(B) MEDICAL CONDITIONS.—The code set 

18 established under subparagraph (A) shall—

19 ‘‘(i) take into account the list of med20 ical conditions developed in the course of 

21 the negotiated rulemaking process con22 ducted under paragraph (1); and 

23 ‘‘(ii) notwithstanding any other provi24 sion of law, be adopted as a standard code 

25 set under section 1173(c).’’. 
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1 (c) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply to services furnished on or after 

3 the date of the enactment of this Act. 

4 SEC. 8. RURAL MENTAL HEALTH CARE ACCESSIBILITY IM5 PROVEMENTS. 

6 (a) INTERDISCIPLINARY GRANT PROGRAM.—Subpart 

7 I of part D of title III of the Public Health Service Act 

8 (42 U.S.C. 254b et seq.) is amended by adding at the end 

9 the following new section: 

10 ‘‘SEC. 330L. INTERDISCIPLINARY GRANT PROGRAM. 

11 ‘‘(a) PROGRAM AUTHORIZED.—The Director of the 

12 Office of Rural Health Policy (of the Health Resources 

13 and Services Administration) shall award grants to eligible 

14 entities to establish interdisciplinary training programs 

15 that include significant mental health training in rural 

16 areas for certain health care providers. 

17 ‘‘(b) DEFINITIONS.—In this section: 

18 ‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible en19 tity’ means a public university or other educational 

20 institution that provides training for mental health 

21 care providers or primary health care providers. 

22 ‘‘(2) MENTAL HEALTH CARE PROVIDER.—The 

23 term ‘mental health care provider’ means—

24 ‘‘(A) a physician with postgraduate train25 ing in a residency program of psychiatry; 
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1 ‘‘(B) a licensed psychologist (as defined by 

2 the Secretary for purposes of section 1861(ii) of 

3 such Act (42 U.S.C. 1395x(ii))); 

4 ‘‘(C) a clinical social worker (as defined in 

5 section 1861(hh)(1) of such Act (42 U.S.C. 

6 1395x(hh)(1)); or

7 ‘‘(D) a clinical nurse specialist (as defined 

8 in section 1861(aa)(5)(B) of such Act (42 

9 U.S.C. 1395x(aa)(5)(B))). 

10 ‘‘(3) PRIMARY HEALTH CARE PROVIDER.—The 

11 term ‘primary health care provider’ includes family 

12 practice, internal medicine, pediatrics, obstetrics and 

13 gynecology, geriatrics, and emergency medicine phy14 sicians as well as physician assistants and nurse 

15 practitioners. 

16 ‘‘(4) RURAL AREA.—The term ‘rural area’ 

17 means a rural area as defined in section 

18 1886(d)(2)(D) of the Social Security Act, or such an 

19 area in a rural census tract of a metropolitan statis20 tical area (as determined under the most recent 

21 modification of the Goldsmith Modification, origi22 nally published in the Federal Register on February 

23 27, 1992 (57 Fed. Reg. 6725)), or any other geo24 graphical area that the Director designates as a 

25 rural area. 
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1 ‘‘(c) DURATION.—Grants awarded under subsection 

2 (a) shall be awarded for a period of 5 years. 

3 ‘‘(d) USE OF FUNDS.—An eligible entity that receives 

4 a grant under subsection (a) shall use funds received 

5 through such grant to administer an interdisciplinary, 

6 side-by-side training program for mental health care pro7 viders and primary health care providers, that includes 

8 providing, under appropriate supervision, health care serv9 ices to patients in underserved, rural areas without regard 

10 to patients’ ability to pay for such services. 

11 ‘‘(e) APPLICATION.—An eligible entity desiring a 

12 grant under subsection (a) shall submit an application to 

13 the Director at such time, in such manner, and containing 

14 such information as the Director may reasonably require, 

15 including—

16 ‘‘(1) a description of the activities which the eli17 gible entity intends to carry out using amounts pro18 vided under the grant; 

19 ‘‘(2) a description of the manner in which the 

20 activities funded under the grant will meet the men21 tal health care needs of underserved rural popu22 lations within the State; and 

23 ‘‘(3) a description of the network agreement 

24 with partnering facilities.
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1 ‘‘(f) EVALUATIONS; REPORT.—Each eligible entity 

2 that receives a grant under this section shall submit to 

3 the Director of the Office of Rural Health Policy (of the 

4 Health Resources and Services Administration) an evalua5 tion describing the programs authorized under this section 

6 and any other information that the Director deems appro7 priate. After receiving such evaluations, the Director shall 

8 submit to the appropriate committees of Congress a report 

9 describing such evaluations. 

10 ‘‘(g) AUTHORIZATION OF APPROPRIATIONS.—There 

11 is authorized to be appropriated to carry out this section, 

12 $100,000,000 for fiscal year 2004 and such sums as may 

13 be necessary for each of the fiscal years 2005 through 

14 2008.’’. 

15 (b) COVERAGE OF MARRIAGE AND FAMILY THERA16 PIST SERVICES AND MENTAL HEALTH COUNSELOR SERV17 ICES UNDER PART B OF THE MEDICARE PROGRAM.—

18 (1) COVERAGE OF SERVICES.—

19 (A) IN GENERAL.—Section 1861(s)(2) (42 

20 U.S.C. 1395x(s)(2)) is amended—

21 (i) in subparagraph (U), by striking 

22 ‘‘and’’ after the semicolon at the end; 

23 (ii) in subparagraph (V)(iii), by in24 serting ‘‘and’’ after the semicolon at the 

25 end; and 
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1 (iii) by adding at the end the fol2 lowing new subparagraph: 

3 ‘‘(W) marriage and family therapist services (as 

4 defined in subsection (ww)(1)) and mental health 

5 counselor services (as defined in subsection 

6 (ww)(3));’’. 

7 (B) DEFINITIONS.—Section 1861 (42 

8 U.S.C. 1395x) is amended by adding at the end 

9 the following new subsection: 

10 ‘‘Marriage and Family Therapist Services; Marriage and 

11 Family Therapist; Mental Health Counselor Serv12 ices; Mental Health Counselor 

13 ‘‘(ww)(1) The term ‘marriage and family therapist 

14 services’ means services performed by a marriage and 

15 family therapist (as defined in paragraph (2)) for the diag16 nosis and treatment of mental illnesses, which the mar17 riage and family therapist is legally authorized to perform 

18 under State law (or the State regulatory mechanism pro19 vided by State law) of the State in which such services 

20 are performed, as would otherwise be covered if furnished 

21 by a physician or as an incident to a physician’s profes22 sional service, but only if no facility or other provider 

23 charges or is paid any amounts with respect to the fur24 nishing of such services. 
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•HR 2333 IH 

1 ‘‘(2) The term ‘marriage and family therapist’ means 

2 an individual who—

3 ‘‘(A) possesses a master’s or doctoral degree 

4 which qualifies for licensure or certification as a 

5 marriage and family therapist pursuant to State 

6 law; 

7 ‘‘(B) after obtaining such degree has performed 

8 at least 2 years of clinical supervised experience in 

9 marriage and family therapy; and 

10 ‘‘(C) in the case of an individual performing 

11 services in a State that provides for licensure or cer12 tification of marriage and family therapists, is li13 censed or certified as a marriage and family thera14 pist in such State. 

15 ‘‘(3) The term ‘mental health counselor services’ 

16 means services performed by a mental health counselor (as 

17 defined in paragraph (4)) for the diagnosis and treatment 

18 of mental illnesses which the mental health counselor is 

19 legally authorized to perform under State law (or the 

20 State regulatory mechanism provided by the State law) of 

21 the State in which such services are performed, as would 

22 otherwise be covered if furnished by a physician or as inci23 dent to a physician’s professional service, but only if no 

24 facility or other provider charges or is paid any amounts 

25 with respect to the furnishing of such services. 
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•HR 2333 IH 

1 ‘‘(4) The term ‘mental health counselor’ means an 

2 individual who—

3 ‘‘(A) possesses a master’s or doctor’s degree in 

4 mental health counseling or a related field; 

5 ‘‘(B) after obtaining such a degree has per6 formed at least 2 years of supervised mental health 

7 counselor practice; and 

8 ‘‘(C) in the case of an individual performing 

9 services in a State that provides for licensure or cer10 tification of mental health counselors or professional 

11 counselors, is licensed or certified as a mental health 

12 counselor or professional counselor in such State.’’. 

13 (C) PROVISION FOR PAYMENT UNDER

14 PART B.—Section 1832(a)(2)(B) (42 U.S.C. 

15 1395k(a)(2)(B)) is amended by adding at the 

16 end the following new clause: 

17 ‘‘(v) marriage and family therapist 

18 services and mental health counselor serv19 ices;’’. 

20 (D) AMOUNT OF PAYMENT.—Section 

21 1833(a)(1) (42 U.S.C. 1395l(a)(1)) is amend22 ed—

23 (i) by striking ‘‘and (U)’’ and insert24 ing ‘‘(U)’’; and
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•HR 2333 IH 

1 (ii) by inserting before the semicolon 

2 at the end the following: ‘‘, and (V) with 

3 respect to marriage and family therapist 

4 services and mental health counselor serv5 ices under section 1861(s)(2)(W), the 

6 amounts paid shall be 80 percent of the 

7 lesser of the actual charge for the services 

8 or 75 percent of the amount determined 

9 for payment of a psychologist under sub10 paragraph (L)’’. 

11 (E) EXCLUSION OF MARRIAGE AND FAM12 ILY THERAPIST SERVICES AND MENTAL

13 HEALTH COUNSELOR SERVICES FROM SKILLED

14 NURSING FACILITY PROSPECTIVE PAYMENT

15 SYSTEM.—Section 1888(e)(2)(A) (42 U.S.C. 

16 1395yy(e)(2)(A)), as amended by section 

17 4(b)(1)(B), is amended—

18 (i) in clause (i)(II), by striking 

19 ‘‘clauses (ii), (iii), and (iv)’’ and inserting 

20 ‘‘clauses (ii), (iii), (iv), and (v)’’; and 

21 (ii) by adding at the end the following 

22 new clause: 

23 ‘‘(v) EXCLUSION OF MARRIAGE AND

24 FAMILY THERAPIST SERVICES AND MEN25 TAL HEALTH COUNSELOR SERVICES.—
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•HR 2333 IH 

1 Services described in this clause are mar2 riage and family therapist services (as de3 fined in subsection (ww)(1)) and mental 

4 health counselor services (as defined in 

5 section 1861(ww)(3)).’’. 

6 (F) INCLUSION OF MARRIAGE AND FAMILY

7 THERAPISTS AND MENTAL HEALTH COUN8 SELORS AS PRACTITIONERS FOR ASSIGNMENT

9 OF CLAIMS.—Section 1842(b)(18)(C) (42 

10 U.S.C. 1395u(b)(18)(C)) is amended by adding 

11 at the end the following new clauses: 

12 ‘‘(vii) A marriage and family therapist (as de13 fined in section 1861(ww)(2)). 

14 ‘‘(viii) A mental health counselor (as defined in 

15 section 1861(ww)(4)).’’. 

16 (c) COVERAGE OF CERTAIN MENTAL HEALTH SERV17 ICES PROVIDED IN CERTAIN SETTINGS.—

18 (1) RURAL HEALTH CLINICS AND FEDERALLY

19 QUALIFIED HEALTH CENTERS.—Section 

20 1861(aa)(1)(B) (42 U.S.C. 1395x(aa)(1)(B)) is 

21 amended by striking ‘‘or by a clinical social worker 

22 (as defined in subsection (hh)(1)),’’ and inserting ‘‘, 

23 by a clinical social worker (as defined in subsection 

24 (hh)(1)), by a marriage and family therapist (as de-
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•HR 2333 IH 

1 fined in subsection (ww)(2)), or by a mental health 

2 counselor (as defined in subsection (ww)(4)),’’. 

3 (2) HOSPICE PROGRAMS.—Section 

4 1861(dd)(2)(B)(i)(III) (42 U.S.C. 

5 1395x(dd)(2)(B)(i)(III)) is amended by inserting ‘‘or 

6 a marriage and family therapist (as defined in sub7 section (ww)(2))’’ after ‘‘social worker’’. 

8 (d) AUTHORIZATION OF MARRIAGE AND FAMILY

9 THERAPISTS TO DEVELOP DISCHARGE PLANS FOR POST10 HOSPITAL SERVICES.—Section 1861(ee)(2)(G) (42 

11 U.S.C. 1395x(ee)(2)(G)) is amended by inserting ‘‘mar12 riage and family therapist (as defined in subsection 

13 (ww)(2)),’’ after ‘‘social worker,’’. 

14 (e) EFFECTIVE DATE.—The amendments made by 

15 subsections (b), (c), and (d) shall apply with respect to 

16 services furnished on or after January 1, 2004. 

17 SEC. 9. RURAL HEALTH SERVICES RESEARCH IMPROVE18 MENTS. 

19 (a) IN GENERAL.—Section 711(b) (42 U.S.C. 

20 912(b)) is amended—

21 (1) in paragraph (3), by striking ‘‘and’’ after 

22 the comma at the end; 

23 (2) in paragraph (4), by striking the period at 

24 the end and inserting ‘‘, and’’; and 
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•HR 2333 IH 

1 (3) by adding at the end the following new 

2 paragraph: 

3 ‘‘(5) have the authority to administer grants to 

4 support rural health services research.’’. 

5 (b) EFFECTIVE DATE.—The amendments made by 

6 subsection (a) shall take effect on January 1, 2004. 

7 SEC. 10. EXCLUSION FOR LOAN PAYMENTS UNDER NA8 TIONAL HEALTH SERVICE CORPS LOAN RE9 PAYMENT PROGRAM. 

10 (a) IN GENERAL.—Section 117 of the Internal Rev11 enue Code of 1986 is amended by adding at the end the 

12 following new subsection: 

13 ‘‘(e) LOAN PAYMENTS UNDER NATIONAL HEALTH

14 SERVICE CORPS LOAN REPAYMENT PROGRAM.—Gross in15 come shall not include any amount received under section 

16 338B(g) of the Public Health Service Act.’’. 

17 (b) EFFECTIVE DATE.—The amendment made by 

18 subsection (a) shall apply to amounts received by an indi19 vidual in taxable years beginning after December 31, 

20 2002.

Æ