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[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[S. 3500 Introduced in Senate (IS)]

109th CONGRESS
  2d Session
                                S. 3500

To amend title XVIII of the Social Security Act to protect and preserve 
    access of Medicare beneficiaries in rural areas to health care 
     providers under the Medicare program, and for other purposes.

_______________________________________________________________________

                   IN THE SENATE OF THE UNITED STATES

                             June 13, 2006

   Mr. Thomas (for himself, Mr. Conrad, Mr. Harkin, Mr. Roberts, Ms. 
Collins, Mr. Dayton, Mr. Salazar, Mr. Domenici, Mr. Burns, Mr. Dorgan, 
Mr. Thune, Mr. Johnson, Mr. Nelson of Nebraska, Ms. Murkowski, and Ms. 
Snowe) introduced the following bill; which was read twice and referred 
                      to the Committee on Finance

_______________________________________________________________________

                                 A BILL

 
To amend title XVIII of the Social Security Act to protect and preserve 
    access of Medicare beneficiaries in rural areas to health care 
     providers under the Medicare program, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Rural Hospital and 
Provider Equity (HoPE) Act of 2006''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Fairness in the Medicare disproportionate share hospital (DSH) 
                            adjustment for rural hospitals.
Sec. 3. Extension and Expansion of Medicare hold harmless provision 
                            under the prospective payment system for 
                            hospital outpatient department (HOPD) 
                            services.
Sec. 4. Improvement of definition of low-volume hospital for purposes 
                            of the Medicare inpatient hospital payment 
                            adjustment.
Sec. 5. Extension of Medicare wage index reclassifications for certain 
                            hospitals.
Sec. 6. Extension of Medicare reasonable costs payments for certain 
                            clinical diagnostic laboratory tests 
                            furnished to hospital patients in certain 
                            rural areas.
Sec. 7. Critical access hospital improvements.
Sec. 8. Capital infrastructure revolving loan program.
Sec. 9. Extension of Medicare incentive payment program for physician 
                            scarcity areas.
Sec. 10. Extension of floor on medicare work geographic adjustment.
Sec. 11. Medicare home health care planning improvements.
Sec. 12. Rural health clinic improvements.
Sec. 13. Community health center collaborative access expansion.
Sec. 14. Applying add-on policy for home health services furnished in a 
                            rural area for 2007.
Sec. 15. Use of medical conditions for coding ambulance services.
Sec. 16. Extension of increased Medicare payments for ground ambulance 
                            services in rural areas.
Sec. 17. Improvement in payments to retain emergency and other capacity 
                            for ambulances in rural areas.
Sec. 18. Coverage of marriage and family therapist services and mental 
                            health counselor services under part B of 
                            the Medicare program.
Sec. 19. Medicare remote monitoring pilot projects.
Sec. 20. Facilitating the provision of telehealth services across State 
                            lines.

SEC. 2. FAIRNESS IN THE MEDICARE DISPROPORTIONATE SHARE HOSPITAL (DSH) 
              ADJUSTMENT FOR RURAL HOSPITALS.

    Section 1886(d)(5)(F)(xiv)(II) of the Social Security Act (42 
U.S.C. 1395ww(d)(5)(F)(xiv)(II)) is amended--
            (1) by striking ``or, in the case'' and all that follows 
        through ``subparagraph (G)(iv)''; and
            (2) by inserting at the end the following new sentence: 
        ``The preceding sentence shall not apply to any hospital with 
        respect to discharges occurring on or after October 1, 2006.''.

SEC. 3. EXTENSION AND EXPANSION OF MEDICARE HOLD HARMLESS PROVISION 
              UNDER THE PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL 
              OUTPATIENT DEPARTMENT (HOPD) SERVICES.

    (a) Extension.--
            (1) In general.--Section 1833(t)(7)(D)(i) of the Social 
        Security Act (42 U.S.C. 1395l(t)(7)(D)(i)), as amended by 
        section 5105 of the Deficit Reduction Act of 2005 (Public Law 
        109-171), is amended--
                    (A) in subclause (I)--
                            (i) by striking ``(I)'';
                            (ii) by striking ``(iii)) located in a 
                        rural area'' and inserting ``(iii))''; and
                            (iii) by striking ``before January 1, 
                        2006'' and inserting ``before January 1, 
                        2009''; and
                    (B) by striking subclause (II).
            (2) Effective date.--The amendments made by paragraph (1) 
        shall apply to covered OPD services furnished on or after 
        January 1, 2006.
    (b) Study and Report.--
            (1) Study.--The Secretary of Health and Human Services 
        shall conduct a study to determine if, under the prospective 
        payment system for hospital outpatient department services 
        under section 1833(t) of the Social Security Act (42 U.S.C. 
        1395l(t)), costs incurred by sole community hospitals (as 
        defined in section 1886(d)(5)(D)(iii) of such Act (42 U.S.C. 
        1395ww(d)(5)(D)(iii))) located in urban areas by ambulatory 
        payment classification groups (APCs) exceed those costs 
        incurred by other hospitals located in urban areas.
            (2) Report.--Not later than January 1, 2008, the Secretary 
        of Health and Human Services shall submit to Congress a report 
        on the study conducted under paragraph (1) together with 
        recommendations for such legislation and administrative action 
        as the Secretary determines to be appropriate.

SEC. 4. IMPROVEMENT OF DEFINITION OF LOW-VOLUME HOSPITAL FOR PURPOSES 
              OF THE MEDICARE INPATIENT HOSPITAL PAYMENT ADJUSTMENT.

    Section 1886(d)(12)(C)(i) of the Social Security Act (42 U.S.C. 
1395ww(d)(12)(C)(i)) is amended by inserting ``(or, beginning with 
fiscal year 2007, 2,000 discharges)'' after ``800 discharges''.

SEC. 5. EXTENSION OF MEDICARE WAGE INDEX RECLASSIFICATIONS FOR CERTAIN 
              HOSPITALS.

    (a) MMA Provision.--Section 508 of the Medicare Prescription Drug, 
Improvement, and Modernization Act of 2003 (42 U.S.C. 1395ww note) is 
amended by adding at the end the following new subsection:
    ``(g) Three-Year Extension for Certain Hospitals.--
            ``(1) In general.--In the case of a hospital described in 
        paragraph (2)--
                    ``(A) subsections (a)(3) and (b) shall be applied 
                by substituting `6-year period' for `3-year period'; 
                and
                    ``(B) the limitation under subsection (e) shall not 
                apply after March 31, 2007.
            ``(2) Hospital described.--A hospital described in this 
        paragraph is a hospital--
                    ``(A) that is reclassified to an area under this 
                section as of the day before the date of enactment of 
                this subsection; and
                    ``(B)(i) that is located in a State with less than 
                10 people per square mile; or
                    ``(ii)(I) that is located in a rural area; and
                    ``(II) for which the Secretary has determined the 
                extension under this subsection to be appropriate.''.
    (b) Additional Provision.--The Secretary of Health and Human 
Services shall extend the special exception reclassification of a sole 
community hospital located in a State with less than 10 people per 
square mile (made under the authority of section 1886(d)(5)(I)(i) of 
the Social Security Act (42 U.S.C. 1395ww(d)(5)(I)(i)) and contained in 
the final rule promulgated by the Secretary in the Federal Register on 
August 11, 2004 (69 Fed. Reg. 49107)) for 3 years through fiscal year 
2010.

SEC. 6. EXTENSION OF MEDICARE REASONABLE COSTS PAYMENTS FOR CERTAIN 
              CLINICAL DIAGNOSTIC LABORATORY TESTS FURNISHED TO 
              HOSPITAL PATIENTS IN CERTAIN RURAL AREAS.

    Section 416(b) of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2282; 42 
U.S.C. 1395l-4(b)) is amended by striking ``2-year'' and inserting ``4-
year''.

SEC. 7. CRITICAL ACCESS HOSPITAL IMPROVEMENTS.

    (a) Clarification of Payment for Clinical Laboratory Tests 
Furnished by Critical Access Hospitals.--
            (1) In general.--Section 1834(g)(4) of the Social Security 
        Act (42 U.S.C. 1395m(g)(4)) is amended--
                    (A) in the heading, by striking ``no beneficiary 
                cost-sharing'' and inserting ``treatment of''; and
                    (B) by adding at the end the following new 
                sentence: ``For purposes of the preceding sentence and 
                section 1861(mm)(3), clinical diagnostic laboratory 
                services furnished by a critical access hospital shall 
                be treated as being furnished as part of outpatient 
                critical access services without regard to whether--
                    ``(A) the individual with respect to whom such 
                services are furnished is physically present in the 
                critical access hospital at the time the specimen is 
                collected;
                    ``(B) such individual is registered as an 
                outpatient on the records of, and receives such 
                services directly from, the critical access hospital; 
                or
                    ``(C) payment is (or, but for this subsection, 
                would be) available for such services under the fee 
                schedule established under section 1833(h).''.
            (2) Effective date.--The amendments made by paragraph (1) 
        shall apply to cost reporting periods beginning on or after 
        October 1, 2003.
    (b) Elimination of Isolation Test for Cost-Based Ambulance 
Reimbursement.--
            (1) In general.--Section 1834(l)(8) of the Social Security 
        Act (42 U.S.C. 1395m(l)(8)) is amended--
                    (A) in subparagraph (B)--
                            (i) by striking ``owned and''; and
                            (ii) by inserting ``(including when such 
                        services are provided by the entity under an 
                        arrangement with the hospital)'' after 
                        ``hospital''; and
                    (B) by striking the comma at the end of 
                subparagraph (B) and all that follows and inserting a 
                period.
            (2) Effective date.--The amendments made by this subsection 
        shall apply to services furnished on or after January 1, 2007.

SEC. 8. CAPITAL INFRASTRUCTURE REVOLVING LOAN PROGRAM.

    (a) In General.--Part A of title XVI of the Public Health Service 
Act (42 U.S.C. 300q et seq.) is amended by adding at the end the 
following new section:

            ``capital infrastructure revolving loan program

    ``Sec. 1603.  (a) Authority To Make and Guarantee Loans.--
            ``(1) Authority to make loans.--The Secretary may make 
        loans from the fund established under section 1602(d) to any 
        rural entity for projects for capital improvements, including--
                    ``(A) the acquisition of land necessary for the 
                capital improvements;
                    ``(B) the renovation or modernization of any 
                building;
                    ``(C) the acquisition or repair of fixed or major 
                movable equipment; and
                    ``(D) such other project expenses as the Secretary 
                determines appropriate.
            ``(2) Authority to guarantee loans.--
                    ``(A) In general.--The Secretary may guarantee the 
                payment of principal and interest for loans made to 
                rural entities for projects for any capital improvement 
                described in paragraph (1) to any non-Federal lender.
                    ``(B) Interest subsidies.--In the case of a 
                guarantee of any loan made to a rural entity under 
                subparagraph (A), the Secretary may pay to the holder 
                of such loan, for and on behalf of the project for 
                which the loan was made, amounts sufficient to reduce 
                (by not more than 3 percent) the net effective interest 
                rate otherwise payable on such loan.
    ``(b) Amount of Loan.--The principal amount of a loan directly made 
or guaranteed under subsection (a) for a project for capital 
improvement may not exceed $5,000,000.
    ``(c) Funding Limitations.--
            ``(1) Government credit subsidy exposure.--The total of the 
        Government credit subsidy exposure under the Credit Reform Act 
        of 1990 scoring protocol with respect to the loans outstanding 
        at any time with respect to which guarantees have been issued, 
        or which have been directly made, under subsection (a) may not 
        exceed $50,000,000 per year.
            ``(2) Total amounts.--Subject to paragraph (1), the total 
        of the principal amount of all loans directly made or 
        guaranteed under subsection (a) may not exceed $250,000,000 per 
        year.
    ``(d) Capital Assessment and Planning Grants.--
            ``(1) Nonrepayable grants.--Subject to paragraph (2), the 
        Secretary may make a grant to a rural entity, in an amount not 
        to exceed $50,000, for purposes of capital assessment and 
        business planning.
            ``(2) Limitation.--The cumulative total of grants awarded 
        under this subsection may not exceed $2,500,000 per year.
    ``(e) Termination of Authority.--The Secretary may not directly 
make or guarantee any loan under subsection (a) or make a grant under 
subsection (d) after September 30, 2010.''.
    (b) Rural Entity Defined.--Section 1624 of the Public Health 
Service Act (42 U.S.C. 300s-3) is amended by adding at the end the 
following new paragraph:
            ``(15)(A) The term `rural entity' includes--
                    ``(i) a rural health clinic, as defined in section 
                1861(aa)(2) of the Social Security Act;
                    ``(ii) any medical facility with at least 1 bed, 
                but with less than 50 beds, that is located in--
                            ``(I) a county that is not part of a 
                        metropolitan statistical area; or
                            ``(II) a rural census tract of a 
                        metropolitan statistical area (as determined 
                        under the most recent modification of the 
                        Goldsmith Modification, originally published in 
                        the Federal Register on February 27, 1992 (57 
                        Fed. Reg. 6725));
                    ``(iii) a hospital that is classified as a rural, 
                regional, or national referral center under section 
                1886(d)(5)(C) of the Social Security Act; and
                    ``(iv) a hospital that is a sole community hospital 
                (as defined in section 1886(d)(5)(D)(iii) of the Social 
                Security Act).
            ``(B) For purposes of subparagraph (A), the fact that a 
        clinic, facility, or hospital has been geographically 
        reclassified under the Medicare program under title XVIII of 
        the Social Security Act shall not preclude a hospital from 
        being considered a rural entity under clause (i) or (ii) of 
        subparagraph (A).''.
    (c) Conforming Amendments.--Section 1602 of the Public Health 
Service Act (42 U.S.C. 300q-2) is amended--
            (1) in subsection (b)(2)(D), by inserting ``or 
        1603(a)(2)(B)'' after ``1601(a)(2)(B)''; and
            (2) in subsection (d)--
                    (A) in paragraph (1)(C), by striking ``section 
                1601(a)(2)(B)'' and inserting ``sections 1601(a)(2)(B) 
                and 1603(a)(2)(B)''; and
                    (B) in paragraph (2)(A), by inserting ``or 
                1603(a)(2)(B)'' after ``1601(a)(2)(B)''.

SEC. 9. EXTENSION OF MEDICARE INCENTIVE PAYMENT PROGRAM FOR PHYSICIAN 
              SCARCITY AREAS.

    Section 1833(u)(1) of the Social Security Act (42 U.S.C. 
1395l(u)(1)) is amended by striking ``before January 1, 2008'' and 
inserting ``before January 1, 2009''.

SEC. 10. EXTENSION OF FLOOR ON MEDICARE WORK GEOGRAPHIC ADJUSTMENT.

    Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w-
4(e)(1)(E)) is amended by striking ``before January 1, 2007'' and 
inserting ``before January 1, 2009''.

SEC. 11. MEDICARE HOME HEALTH CARE PLANNING IMPROVEMENTS.

    (a) In General.--Section 1814(a)(2) of the Social Security Act (42 
U.S.C. 1395f(a)(2)), in the matter preceding subparagraph (A), is 
amended--
            (1) by striking ``subparagraph (B)'' and inserting 
        ``subparagraphs (B) and (C)'';
            (2) by inserting ``(as those terms are defined in section 
        1861(aa)(5))'' after ``clinical nurse specialist'';
            (3) by inserting ``or home health agency (as the case may 
        be)'' after ``facility''; and
            (4) by inserting ``(or in the case of services described in 
        subparagraph (C), a physician assistant (as defined in 
        1861(aa)(5)) under the supervision of a physician)'' after 
        ``collaboration with a physician''.
    (b) Conforming Amendments.--(1) Section 1814(a) of the Social 
Security Act (42 U.S.C. 1395f(a)) is amended--
            (A) in paragraph (2)(C), by inserting ``a nurse 
        practitioner, a clinical nurse specialist, or a physician 
        assistant (as the case may be)'' after ``physician'' each place 
        it appears;
            (B) in the second sentence, by striking ``or clinical nurse 
        specialist'' and inserting ``clinical nurse specialist, or 
        physician assistant'';
            (C) in the third sentence--
                    (i) by striking ``physician certification'' and 
                inserting ``certification'';
                    (ii) by inserting ``(or on January 1, 2007, in the 
                case of regulations to implement the amendments made by 
                section 11 of the Rural Hospital and Provider Equity 
                (HoPE) Act of 2006)'' after ``1981''; and
                    (iii) by striking ``a physician who'' and inserting 
                ``a physician, nurse practitioner, clinical nurse 
                specialist, or physician assistant who''; and
            (D) in the fourth sentence, by inserting ``, nurse 
        practitioner, clinical nurse specialist, or physician 
        assistant'' after ``physician''.
    (2) Section 1835(a) of the Social Security Act (42 U.S.C. 1395n(a)) 
is amended--
            (A) in paragraph (2)--
                    (i) in the matter preceding subparagraph (A), by 
                inserting ``or, in the case of services described in 
                subparagraph (A), a physician, or a nurse practitioner 
                or clinical nurse specialist (as those terms are 
                defined in 1861(aa)(5)), who does not have a direct or 
                indirect employment relationship with the home health 
                agency but is working in collaboration with a physician 
                (or a physician assistant (as defined in 1861(aa)(5)) 
                under the supervision of a physician)'' after ``a 
                physician''; and
                    (ii) in subparagraph (A) by inserting ``a nurse 
                practitioner, a clinical nurse specialist, or a 
                physician assistant (as the case may be)'' after 
                ``physician'' each place it appears;
            (B) in the third sentence, by inserting ``, nurse 
        practitioner, clinical nurse specialist, or physician assistant 
        (as the case may be)'' after physician;
            (C) in the fourth sentence--
                    (i) by striking ``physician certification'' and 
                inserting ``certification'';
                    (ii) by inserting ``(or on January 1, 2007, in the 
                case of regulations to implement the amendments made by 
                section 11 of the Rural Hospital and Provider Equity 
                (HoPE) Act of 2006)'' after ``1981''; and
                    (iii) by striking ``a physician who'' and inserting 
                ``a physician, nurse practitioner, clinical nurse 
                specialist, or physician assistant who''; and
            (D) in the fifth sentence, by inserting ``, nurse 
        practitioner, clinical nurse specialist, or physician 
        assistant'' after ``physician''.
    (3) Section 1861 of the Social Security Act (42 U.S.C. 1395x) is 
amended--
            (A) in subsection (m)--
                    (i) in the matter preceding paragraph (1)--
                            (I) by inserting ``, or a nurse 
                        practitioner, clinical nurse specialist, or 
                        physician assistant (as those terms are defined 
                        in subsection (aa)(5))'' after ``physician'' 
                        the first place it appears; and
                            (II) by inserting ``or a nurse 
                        practitioner, clinical nurse specialist, or 
                        physician assistant'' after ``physician'' the 
                        second place it appears; and
                    (ii) in paragraph (3), by inserting ``or a nurse 
                practitioner, clinical nurse specialist, or physician 
                assistant'' after ``physician''; and
            (B) in subsection (o)(2)--
                    (i) by inserting ``, nurse practitioners, clinical 
                nurse specialists, or physician assistants (as those 
                terms are defined in subsection (aa)(5))'' after 
                ``physicians''; and
                    (ii) by inserting ``, nurse practitioner, clinical 
                nurse specialist, physician assistant,'' after 
                ``physician''
    (4) Section 1895 of the Social Security Act (42 U.S.C. 1395fff) is 
amended--
            (A) in subsection (c)(1), by inserting ``, or the nurse 
        practitioner, clinical nurse specialist, or physician assistant 
        (as those terms are defined in section 1861(aa)(5)),'' after 
        ``physician''; and
            (B) in subsection (e)--
                    (i) in paragraph (1)(A), by inserting ``, or a 
                nurse practitioner, clinical nurse specialist, or 
                physician assistant (as those terms are defined in 
                section 1861(aa)(5)),'' after ``physician''; and
                    (ii) in paragraph (2)--
                            (I) in the heading, by striking ``Physician 
                        certification'' and inserting ``Rule of 
                        construction regarding requirement for 
                        certification''; and
                            (II) by striking ``physician''.
    (c) Effective Date.--The amendments made by this section shall 
apply to items and services furnished on or after January 1, 2007.

SEC. 12. RURAL HEALTH CLINIC IMPROVEMENTS.

    Section 1833(f) of the Social Security Act (42 U.S.C. 1395l(f)) is 
amended--
            (1) in paragraph (1), by striking ``, and'' at the end and 
        inserting a semicolon;
            (2) in paragraph (2)--
                    (A) by inserting ``(before 2007)'' after ``in a 
                subsequent year''; and
                    (B) by striking the period at the end and inserting 
                a semicolon; and
            (3) by adding at the end the following new paragraphs:
            ``(3) in 2007, at $82 per visit; and
            ``(4) in a subsequent year, at the limit established under 
        this subsection for the previous year increased by the 
        percentage increase in the MEI (as so defined) applicable to 
        primary care services (as so defined) furnished as of the first 
        day of that year.''

SEC. 13. COMMUNITY HEALTH CENTER COLLABORATIVE ACCESS EXPANSION.

    Section 330 of the Public Health Service Act (42 U.S.C. 254b) is 
amended by adding at the end the following:
    ``(s) Miscellaneous Provisions.--
            ``(1) Rule of construction with respect to rural health 
        clinics.--
                    ``(A) In general.--Nothing in this section shall be 
                construed to prevent a community health center from 
                contracting with a federally certified rural health 
                clinic (as defined by section 1861(aa)(2) of the Social 
                Security Act) for the delivery of primary health care 
                services that are available at the rural health clinic 
                to individuals who would otherwise be eligible for free 
                or reduced cost care if that individual were able to 
                obtain that care at the community health center. Such 
                services may be limited in scope to those primary 
                health care services available in that rural health 
                clinic.
                    ``(B) Assurances.--In order for a rural health 
                clinic to receive funds under this section through a 
                contract with a community health center under paragraph 
                (1), such rural health clinic shall establish policies 
                to ensure--
                            ``(i) nondiscrimination based upon the 
                        ability of a patient to pay; and
                            ``(ii) the establishment of a sliding fee 
                        scale for low-income patients.''.

SEC. 14. APPLYING ADD-ON POLICY FOR HOME HEALTH SERVICES FURNISHED IN A 
              RURAL AREA FOR 2007.

    Section 421 of Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2283), as 
amended by section 5201(b) of the Deficit Reduction Act of 2005 (Public 
Law 109-171), is amended--
            (1) in the heading, by striking ``one-year'' and inserting 
        ``temporary''; and
            (2) in subsection (a), by striking ``before January 1, 
        2007'' and inserting ``before January 1, 2008''.

SEC. 15. USE OF MEDICAL CONDITIONS FOR CODING AMBULANCE SERVICES.

    Section 1834(l)(7) of the Social Security Act (42 U.S.C. 
1395m(l)(7)) is amended to read as follows:
            ``(7) Coding system.--
                    ``(A) In general.--The Secretary shall, in 
                accordance with section 1173(c)(1)(B) and not later 
                than January 1, 2007, establish a mandatory system or 
                systems for the coding of claims for ambulance services 
                for which payment is made under this subsection, 
                including a code set specifying the medical condition 
                of the individual who is transported and the level of 
                service that is appropriate for the transportation of 
                an individual with that medical condition.
                    ``(B) Medical conditions.--The code set established 
                under subparagraph (A) shall take into account the list 
                of medical conditions developed in the course of the 
                negotiated rulemaking process conducted under paragraph 
                (1).''.

SEC. 16. EXTENSION OF INCREASED MEDICARE PAYMENTS FOR GROUND AMBULANCE 
              SERVICES IN RURAL AREAS.

    Section 1834(l)(13) of the Social Security Act (42 U.S.C. 
1395m(l)(13)) is amended--
            (1) in subparagraph (A), in the matter preceding clause 
        (i), by striking ``before January 1, 2007'' and inserting 
        ``before January 1, 2008'';
            (2) in subparagraph (B), in the heading, by striking 
        ``after 2006'' and inserting ``after 2007''.

SEC. 17. IMPROVEMENT IN PAYMENTS TO RETAIN EMERGENCY AND OTHER CAPACITY 
              FOR AMBULANCES IN RURAL AREAS.

    (a) In General.--Section 1834(l) of the Social Security Act (42 
U.S.C. 1395m(l)) is amended by adding at the end the following new 
paragraph:
            ``(15) Additional payments for providers furnishing 
        ambulance services in rural areas.--
                    ``(A) In general.--In the case of ground ambulance 
                services furnished on or after January 1, 2007, for 
                which the transportation originates in a rural area (as 
                determined under subparagraph (B)), the Secretary shall 
                provide for a percent increase in the base rate of the 
                fee schedule for a trip identified under this 
                subsection.
                    ``(B) Identification of rural areas.--The 
                Secretary, in consultation with the Office of Rural 
                Health Policy, shall use the Rural-Urban Commuting 
                Areas (RUCA) coding system, adopted by that Office, to 
                designate rural areas for the purposes of this 
                paragraph. A rural area is any area in RUCA levels 2 
                through 10 and any unclassified area.
                    ``(C) Tiering of rural areas.--The Secretary shall 
                designate 4 tiers of rural areas, using a ZIP Code 
                population-based methodology generated by the RUCA 
                coding system, as follows:
                            ``(i) Tier 1.--A rural area that is a high 
                        metropolitan commuting area, in which 30 
                        percent or more of the commuting flow is to an 
                        urban area, as designated by the Bureau of the 
                        Census (RUCA level 2).
                            ``(ii) Tier 2.--A rural area that is a low 
                        metropolitan commuting area, in which less than 
                        30 percent of the commuting flow is to an urban 
                        area or to a large town, as designated by the 
                        Bureau of the Census (RUCA levels 3-6).
                            ``(iii) Tier 3.--A rural area that is a 
                        small town core, as designated by the Bureau of 
                        the Census, in which no significant portion of 
                        the commuting flow is to an area of population 
                        greater than 10,000 people (RUCA levels 7-9).
                            ``(iv) Tier 4.--A rural area in which there 
                        is no dominant commuting flow (RUCA level 10) 
                        and any unclassified area.
                The Secretary shall consult with the Office of Rural 
                Health Policy not less often than every 2 years to 
                update the designation of rural areas in accordance 
                with any changes that are made to the RUCA system.
                    ``(D) Payment adjustments for trips in rural 
                areas.--The Secretary shall adjust the payment rate 
                under this section for ambulance trips that originate 
                in each of the tiers established in subparagraph (C) 
                according to the national average cost of full-cost 
                providers for providing ambulance services in each such 
                tier.''.
    (b) Review of Payments for Rural Ambulance Services and Report to 
Congress.--
            (1) Review.--Not later than July 1, 2009, the Secretary of 
        Health and Human Services shall review the system for adjusting 
        payments for rural ambulance services under section 1834(l)(15) 
        of the Social Security Act, as added by subsection (a), to 
        determine the adequacy and appropriateness of such adjustments. 
        In conducting such review, the Secretary shall consult with 
        providers and suppliers affected by such adjustments and with 
        representatives of the ambulance industry generally to 
        determine--
                    (A) whether such adjustments adequately cover the 
                additional costs incurred in serving areas of low 
                population density; and
                    (B) whether the tiered structure for making such 
                adjustments appropriately reflects the difference in 
                costs of providing services in different types of rural 
                areas.
            (2) Report.--Not later than January 1, 2010, the Secretary 
        shall submit to Congress a report on the review conducted under 
        paragraph (1) together with any recommendations for revision to 
        the systems for adjusting payments for ambulance services in 
        rural areas that the Secretary of Health and Human Services 
        determines appropriate.
    (c) Conforming Amendments.--(1) Section 1834(l) of the Social 
Security Act (42 U.S.C. 1395m(l)), as amended by subsection (a), is 
amended by adding at the end the following new paragraph:
            ``(16) Designation of rural areas for mileage payment 
        purposes.--In establishing any differential in the amount of 
        payment for mileage between rural and urban areas in the fee 
        schedule established under paragraph (1), the Secretary shall, 
        in the case of ambulance services furnished on or after January 
        1, 2007, identify rural areas in the same manner as provided in 
        paragraph (15)(B).''.
    (2) Section 1834(l)(12)(A) of the Social Security Act (42 U.S.C. 
1395m(l)(12)(A)) is amended by striking ``January 1, 2010'' and 
inserting ``January 1, 2007''.
    (3) Section 1834(l)(13)(A)(i) of the Social Security Act (42 U.S.C. 
1395m(l)(13)(A)(i)) is amended--
            (A) by inserting ``(or in the case of such services 
        furnished in 2007, in a rural area identified by the Secretary 
        under paragraph (15)(B))'' after ``such paragraph''; and
            (B) by striking ``paragraphs (11) and (12)'' and inserting 
        ``paragraphs (11), (12), and (15)''.

SEC. 18. COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES AND MENTAL 
              HEALTH COUNSELOR SERVICES UNDER PART B OF THE MEDICARE 
              PROGRAM.

    (a) Coverage of Services.--
            (1) In general.--Section 1861(s)(2) of the Social Security 
        Act (42 U.S.C. 1395x(s)(2)), as amended by section 5112 of the 
        Deficit Reduction Act of 2005 (Public Law 109-171), is 
        amended--
                    (A) in subparagraph (Z), by striking ``and'' at the 
                end;
                    (B) in subparagraph (AA), by inserting ``and'' at 
                the end; and
                    (C) by adding at the end the following new 
                subparagraph:
            ``(BB) marriage and family therapist services (as defined 
        in subsection (ccc)(1)) and mental health counselor services 
        (as defined in subsection (ccc)(3));''.
            (2) Definitions.--Section 1861 of the Social Security Act 
        (42 U.S.C. 1395x), as amended by section 5112 of the Deficit 
        Reduction Act of 2005 (Public Law 109-171), is amended by 
        adding at the end the following new subsection:

     ``Marriage and Family Therapist Services; Marriage and Family 
  Therapist; Mental Health Counselor Services; Mental Health Counselor

    ``(ccc)(1) The term `marriage and family therapist services' means 
services performed by a marriage and family therapist (as defined in 
paragraph (2)) for the diagnosis and treatment of mental illnesses, 
which the marriage and family therapist is legally authorized to 
perform under State law (or the State regulatory mechanism provided by 
State law) of the State in which such services are performed, as would 
otherwise be covered if furnished by a physician or as an incident to a 
physician's professional service, but only if no facility or other 
provider charges or is paid any amounts with respect to the furnishing 
of such services.
    ``(2) The term `marriage and family therapist' means an individual 
who--
            ``(A) possesses a master's or doctoral degree which 
        qualifies for licensure or certification as a marriage and 
        family therapist pursuant to State law;
            ``(B) after obtaining such degree has performed at least 2 
        years of clinical supervised experience in marriage and family 
        therapy; and
            ``(C) in the case of an individual performing services in a 
        State that provides for licensure or certification of marriage 
        and family therapists, is licensed or certified as a marriage 
        and family therapist in such State.
    ``(3) The term `mental health counselor services' means services 
performed by a mental health counselor (as defined in paragraph (4)) 
for the diagnosis and treatment of mental illnesses which the mental 
health counselor is legally authorized to perform under State law (or 
the State regulatory mechanism provided by the State law) of the State 
in which such services are performed, as would otherwise be covered if 
furnished by a physician or as incident to a physician's professional 
service, but only if no facility or other provider charges or is paid 
any amounts with respect to the furnishing of such services.
    ``(4) The term `mental health counselor' means an individual who--
            ``(A) possesses a master's or doctor's degree in mental 
        health counseling or a related field;
            ``(B) after obtaining such a degree has performed at least 
        2 years of supervised mental health counselor practice; and
            ``(C) in the case of an individual performing services in a 
        State that provides for licensure or certification of mental 
        health counselors or professional counselors, is licensed or 
        certified as a mental health counselor or professional 
        counselor in such State.''.
            (3) Provision for payment under part b.--Section 
        1832(a)(2)(B) of the Social Security Act (42 U.S.C. 
        1395k(a)(2)(B)) is amended by adding at the end the following 
        new clause:
                            ``(v) marriage and family therapist 
                        services and mental health counselor 
                        services;''.
            (4) Amount of payment.--Section 1833(a)(1) of the Social 
        Security Act (42 U.S.C. 1395l(a)(1)) is amended--
                    (A) by striking ``and (V)'' and inserting ``(V)''; 
                and
                    (B) by inserting before the semicolon at the end 
                the following: ``, and (W) with respect to marriage and 
                family therapist services and mental health counselor 
                services under section 1861(s)(2)(BB), the amounts paid 
                shall be 80 percent of the lesser of the actual charge 
                for the services or 75 percent of the amount determined 
                for payment of a psychologist under subparagraph (L)''.
            (5) Exclusion of marriage and family therapist services and 
        mental health counselor services from skilled nursing facility 
        prospective payment system.--Section 1888(e)(2)(A)(ii) of the 
        Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended 
        by inserting ``marriage and family therapist services (as 
        defined in section 1861(ccc)(1)), mental health counselor 
        services (as defined in section 1861(ccc)(3)),'' after 
        ``qualified psychologist services,''.
            (6) Inclusion of marriage and family therapists and mental 
        health counselors as practitioners for assignment of claims.--
        Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 
        1395u(b)(18)(C)) is amended by adding at the end the following 
        new clauses:
            ``(vii) A marriage and family therapist (as defined in 
        section 1861(ccc)(2)).
            ``(viii) A mental health counselor (as defined in section 
        1861(ccc)(4)).''.
    (b) Coverage of Certain Mental Health Services Provided in Certain 
Settings.--
            (1) Rural health clinics and federally qualified health 
        centers.--Section 1861(aa)(1)(B) of the Social Security Act (42 
        U.S.C. 1395x(aa)(1)(B)) is amended by striking ``or by a 
        clinical social worker (as defined in subsection (hh)(1)),'' 
        and inserting ``, by a clinical social worker (as defined in 
        subsection (hh)(1)), by a marriage and family therapist (as 
        defined in subsection (ccc)(2)), or by a mental health 
        counselor (as defined in subsection (ccc)(4)),''.
            (2) Hospice programs.--Section 1861(dd)(2)(B)(i)(III) of 
        the Social Security Act (42 U.S.C. 1395x(dd)(2)(B)(i)(III)) is 
        amended by inserting ``or one marriage and family therapist (as 
        defined in subsection (ccc)(2))'' after ``social worker''.
    (c) Authorization of Marriage and Family Therapists to Develop 
Discharge Plans for Post-Hospital Services.--Section 1861(ee)(2)(G) of 
the Social Security Act (42 U.S.C. 1395x(ee)(2)(G)) is amended by 
inserting ``marriage and family therapist (as defined in subsection 
(ccc)(2)),'' after ``social worker,''.
    (d) Effective Date.--The amendments made by this section shall 
apply with respect to services furnished on or after January 1, 2007.

SEC. 19. MEDICARE REMOTE MONITORING PILOT PROJECTS.

    (a) Pilot Projects.--
            (1) In general.--Not later than 9 months after the date of 
        enactment of this Act, the Secretary of Health and Human 
        Services (in this section referred to as the ``Secretary'') 
        shall conduct pilot projects under title XVIII of the Social 
        Security Act for the purpose of providing incentives to home 
        health agencies to utilize home monitoring and communications 
        technologies that--
                    (A) enhance health outcomes for Medicare 
                beneficiaries; and
                    (B) reduce expenditures under such title.
            (2) Site requirements.--
                    (A) Urban and rural.--The Secretary shall conduct 
                the pilot projects under this section in both urban and 
                rural areas.
                    (B) Site in a small state.--The Secretary shall 
                conduct at least 3 of the pilot projects in a State 
                with a population of less than 1,000,000.
            (3) Definition of home health agency.--In this section, the 
        term ``home health agency'' has the meaning given that term in 
        section 1861(o) of the Social Security Act (42 U.S.C. 
        1395x(o)).
    (b) Medicare Beneficiaries Within the Scope of Projects.--The 
Secretary shall specify the criteria for identifying those Medicare 
beneficiaries who shall be considered within the scope of the pilot 
projects under this section for purposes of the application of 
subsection (c) and for the assessment of the effectiveness of the home 
health agency in achieving the objectives of this section. Such 
criteria may provide for the inclusion in the projects of Medicare 
beneficiaries who begin receiving home health services under title 
XVIII of the Social Security Act after the date of the implementation 
of the projects.
    (c) Incentives.--
            (1) Performance targets.--The Secretary shall establish for 
        each home health agency participating in a pilot project under 
        this section a performance target using one of the following 
        methodologies, as determined appropriate by the Secretary:
                    (A) Adjusted historical performance target.--The 
                Secretary shall establish for the agency--
                            (i) a base expenditure amount equal to the 
                        average total payments made to the agency under 
                        parts A and B of title XVIII of the Social 
                        Security Act for Medicare beneficiaries 
                        determined to be within the scope of the pilot 
                        project in a base period determined by the 
                        Secretary; and
                            (ii) an annual per capita expenditure 
                        target for such beneficiaries, reflecting the 
                        base expenditure amount adjusted for risk and 
                        adjusted growth rates.
                    (B) Comparative performance target.--The Secretary 
                shall establish for the agency a comparative 
                performance target equal to the average total payments 
                under such parts A and B during the pilot project for 
                comparable individuals in the same geographic area that 
                are not determined to be within the scope of the pilot 
                project.
            (2) Incentive.--Subject to paragraph (3), the Secretary 
        shall pay to each participating home care agency an incentive 
        payment for each year under the pilot project equal to a 
        portion of the Medicare savings realized for such year relative 
        to the performance target under paragraph (1).
            (3) Limitation on expenditures.--The Secretary shall limit 
        incentive payments under this section in order to ensure that 
        the aggregate expenditures under title XVIII of the Social 
        Security Act (including incentive payments under this 
        subsection) do not exceed the amount that the Secretary 
        estimates would have been expended if the pilot projects under 
        this section had not been implemented.
    (d) Waiver Authority.--The Secretary may waive such provisions of 
titles XI and XVIII of the Social Security Act as the Secretary 
determines to be appropriate for the conduct of the pilot projects 
under this section.
    (e) Report to Congress.--Not later than 5 years after the date that 
the first pilot project under this section is implemented, the 
Secretary shall submit to Congress a report on the pilot projects. Such 
report shall contain a detailed description of issues related to the 
expansion of the projects under subsection (f) and recommendations for 
such legislation and administrative actions as the Secretary considers 
appropriate.
    (f) Expansion.--If the Secretary determines that any of the pilot 
projects under this section enhance health outcomes for Medicare 
beneficiaries and reduce expenditures under title XVIII of the Social 
Security Act, the Secretary may initiate comparable projects in 
additional areas.
    (g) Incentive Payments Have No Effect on Other Medicare Payments to 
Agencies.--An incentive payment under this section--
            (1) shall be in addition to the payments that a home health 
        agency would otherwise receive under title XVIII of the Social 
        Security Act for the provision of home health services; and
            (2) shall have no effect on the amount of such payments.

SEC. 20. FACILITATING THE PROVISION OF TELEHEALTH SERVICES ACROSS STATE 
              LINES.

    (a) In General.--For purposes of expediting the provision of 
telehealth services, for which payment is made under the Medicare 
program, across State lines, the Secretary of Health and Human Services 
shall, in consultation with representatives of States, physicians, 
health care practitioners, and patient advocates, encourage and 
facilitate the adoption of provisions allowing for multistate 
practitioner practice across State lines.
    (b) Definitions.--In subsection (a):
            (1) Telehealth service.--The term ``telehealth service'' 
        has the meaning given that term in subparagraph (F) of section 
        1834(m)(4) of the Social Security Act (42 U.S.C. 1395m(m)(4)).
            (2) Physician, practitioner.--The terms ``physician'' and 
        ``practitioner'' have the meaning given those terms in 
        subparagraphs (D) and (E), respectively, of such section.
            (3) Medicare program.--The term ``Medicare program'' means 
        the program of health insurance administered by the Secretary 
        of Health and Human Services under title XVIII of the Social 
        Security Act (42 U.S.C. 1395 et seq.).
                                 <all>
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