II 

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. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

5 ‘‘Rural Hospital and Provider Equity (HoPE) Act of 

6 2006’’. 


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1 (b) TABLE OF CONTENTS.—The table of contents of 

2 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. 

3 SEC. 2. FAIRNESS IN THE MEDICARE DISPROPORTIONATE 

4 SHARE HOSPITAL (DSH) ADJUSTMENT FOR 

5 RURAL HOSPITALS. 

6 Section 1886(d)(5)(F)(xiv)(II) of the Social Security 

7 Act (42 U.S.C. 1395ww(d)(5)(F)(xiv)(II)) is amended— 

8 (1) by striking ‘‘or, in the case’’ and all that 

9 follows through ‘‘subparagraph (G)(iv)’’; and 

10 (2) by inserting at the end the following new 

11 sentence: ‘‘The preceding sentence shall not apply to 


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1 any hospital with respect to discharges occurring on 

2 or after October 1, 2006.’’. 

3 SEC. 3. EXTENSION AND EXPANSION OF MEDICARE HOLD 

4 HARMLESS PROVISION UNDER THE PRO5 SPECTIVE PAYMENT SYSTEM FOR HOSPITAL 

6 OUTPATIENT DEPARTMENT (HOPD) SERV7 ICES. 

8 (a) EXTENSION.— 

9 (1) IN GENERAL.—Section 1833(t)(7)(D)(i) of 

10 the Social Security Act (42 U.S.C. 

11 1395l(t)(7)(D)(i)), as amended by section 5105 of 

12 the Deficit Reduction Act of 2005 (Public Law 109– 

13 171), is amended— 

14 (A) in subclause (I)— 

15 (i) by striking ‘‘(I)’’; 

16 (ii) by striking ‘‘(iii)) located in a 

17 rural area’’ and inserting ‘‘(iii))’’; and 

18 (iii) by striking ‘‘before January 1, 

19 2006’’ and inserting ‘‘before January 1, 

20 2009’’; and 

21 (B) by striking subclause (II). 

22 (2) EFFECTIVE DATE.—The amendments made 

23 by paragraph (1) shall apply to covered OPD serv24 ices furnished on or after January 1, 2006. 

25 (b) STUDY AND REPORT.— 


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1 (1) STUDY.—The Secretary of Health and 

2 Human Services shall conduct a study to determine 

3 if, under the prospective payment system for hos4 pital outpatient department services under section 

5 1833(t) of the Social Security Act (42 U.S.C. 

6 1395l(t)), costs incurred by sole community hos7 pitals (as defined in section 1886(d)(5)(D)(iii) of 

8 such Act (42 U.S.C. 1395ww(d)(5)(D)(iii))) located 

9 in urban areas by ambulatory payment classification 

10 groups (APCs) exceed those costs incurred by other 

11 hospitals located in urban areas. 

12 (2) REPORT.—Not later than January 1, 2008, 

13 the Secretary of Health and Human Services shall 

14 submit to Congress a report on the study conducted 

15 under paragraph (1) together with recommendations 

16 for such legislation and administrative action as the 

17 Secretary determines to be appropriate. 

18 SEC. 4. IMPROVEMENT OF DEFINITION OF LOW-VOLUME 

19 HOSPITAL FOR PURPOSES OF THE MEDICARE 

20 INPATIENT HOSPITAL PAYMENT ADJUST21 MENT. 

22 Section 1886(d)(12)(C)(i) of the Social Security Act 

23 (42 U.S.C. 1395ww(d)(12)(C)(i)) is amended by inserting 

24 ‘‘(or, beginning with fiscal year 2007, 2,000 discharges)’’ 

25 after ‘‘800 discharges’’. 


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1 SEC. 5. EXTENSION OF MEDICARE WAGE INDEX RECLASSI2 FICATIONS FOR CERTAIN HOSPITALS. 

3 (a) MMA PROVISION.—Section 508 of the Medicare 

4 Prescription Drug, Improvement, and Modernization Act 

5 of 2003 (42 U.S.C. 1395ww note) is amended by adding 

6 at the end the following new subsection: 

7 ‘‘(g) THREE-YEAR EXTENSION FOR CERTAIN HOS8 PITALS.— 

9 ‘‘(1) IN GENERAL.—In the case of a hospital 

10 described in paragraph (2)— 

11 ‘‘(A) subsections (a)(3) and (b) shall be 

12 applied by substituting ‘6-year period’ for ‘3- 

13 year period’; and 

14 ‘‘(B) the limitation under subsection (e) 

15 shall not apply after March 31, 2007. 

16 ‘‘(2) HOSPITAL DESCRIBED.—A hospital de17 scribed in this paragraph is a hospital— 

18 ‘‘(A) that is reclassified to an area under 

19 this section as of the day before the date of en20 actment of this subsection; and 

21 ‘‘(B)(i) that is located in a State with less 

22 than 10 people per square mile; or 

23 ‘‘(ii)(I) that is located in a rural area; and 

24 ‘‘(II) for which the Secretary has deter25 mined the extension under this subsection to be 

26 appropriate.’’. 


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1 (b) ADDITIONAL PROVISION.—The Secretary of 

2 Health and Human Services shall extend the special ex3 ception reclassification of a sole community hospital lo4 cated in a State with less than 10 people per square mile 

5 (made under the authority of section 1886(d)(5)(I)(i) of 

6 the Social Security Act (42 U.S.C. 1395ww(d)(5)(I)(i)) 

7 and contained in the final rule promulgated by the Sec8 retary in the Federal Register on August 11, 2004 (69 

9 Fed. Reg. 49107)) for 3 years through fiscal year 2010. 

10 SEC. 6. EXTENSION OF MEDICARE REASONABLE COSTS 

11 PAYMENTS FOR CERTAIN CLINICAL DIAG12 NOSTIC LABORATORY TESTS FURNISHED TO 

13 HOSPITAL PATIENTS IN CERTAIN RURAL 

14 AREAS. 

15 Section 416(b) of the Medicare Prescription Drug, 

16 Improvement, and Modernization Act of 2003 (Public Law 

17 108–173; 117 Stat. 2282; 42 U.S.C. 1395l–4(b)) is 

18 amended by striking ‘‘2-year’’ and inserting ‘‘4-year’’. 

19 SEC. 7. CRITICAL ACCESS HOSPITAL IMPROVEMENTS. 

20 (a) CLARIFICATION OF PAYMENT FOR CLINICAL

21 LABORATORY TESTS FURNISHED BY CRITICAL ACCESS

22 HOSPITALS.— 

23 (1) IN GENERAL.—Section 1834(g)(4) of the 

24 Social Security Act (42 U.S.C. 1395m(g)(4)) is 

25 amended— 


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1 (A) in the heading, by striking ‘‘NO BENE2 FICIARY COST-SHARING’’ and inserting ‘‘TREAT3 MENT OF’’; and 

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

5 sentence: ‘‘For purposes of the preceding sen6 tence and section 1861(mm)(3), clinical diag7 nostic laboratory services furnished by a critical 

8 access hospital shall be treated as being fur9 nished as part of outpatient critical access serv10 ices without regard to whether— 

11 ‘‘(A) the individual with respect to whom 

12 such services are furnished is physically present 

13 in the critical access hospital at the time the 

14 specimen is collected; 

15 ‘‘(B) such individual is registered as an 

16 outpatient on the records of, and receives such 

17 services directly from, the critical access hos18 pital; or 

19 ‘‘(C) payment is (or, but for this sub20 section, would be) available for such services 

21 under the fee schedule established under section 

22 1833(h).’’. 

23 (2) EFFECTIVE DATE.—The amendments made 

24 by paragraph (1) shall apply to cost reporting peri25 ods beginning on or after October 1, 2003. 


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1 (b) ELIMINATION OF ISOLATION TEST FOR COST2 BASED AMBULANCE REIMBURSEMENT.— 

3 (1) IN GENERAL.—Section 1834(l)(8) of the 

4 Social Security Act (42 U.S.C. 1395m(l)(8)) is 

5 amended— 

6 (A) in subparagraph (B)— 

7 (i) by striking ‘‘owned and’’; and 

8 (ii) by inserting ‘‘(including when 

9 such services are provided by the entity 

10 under an arrangement with the hospital)’’ 

11 after ‘‘hospital’’; and 

12 (B) by striking the comma at the end of 

13 subparagraph (B) and all that follows and in14 serting a period. 

15 (2) EFFECTIVE DATE.—The amendments made 

16 by this subsection shall apply to services furnished 

17 on or after January 1, 2007. 

18 SEC. 8. CAPITAL INFRASTRUCTURE REVOLVING LOAN PRO19 GRAM. 

20 (a) IN GENERAL.—Part A of title XVI of the Public 

21 Health Service Act (42 U.S.C. 300q et seq.) is amended 

22 by adding at the end the following new section: 

23 ‘‘CAPITAL INFRASTRUCTURE REVOLVING LOAN PROGRAM

24 ‘‘SEC. 1603. (a) AUTHORITY TO MAKE AND GUAR25 ANTEE LOANS.— 


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1 ‘‘(1) AUTHORITY TO MAKE LOANS.—The Sec2 retary may make loans from the fund established 

3 under section 1602(d) to any rural entity for 

4 projects for capital improvements, including— 

5 ‘‘(A) the acquisition of land necessary for 

6 the capital improvements; 

7 ‘‘(B) the renovation or modernization of 

8 any building; 

9 ‘‘(C) the acquisition or repair of fixed or 

10 major movable equipment; and 

11 ‘‘(D) such other project expenses as the 

12 Secretary determines appropriate. 

13 ‘‘(2) AUTHORITY TO GUARANTEE LOANS.— 

14 ‘‘(A) IN GENERAL.—The Secretary may 

15 guarantee the payment of principal and interest 

16 for loans made to rural entities for projects for 

17 any capital improvement described in paragraph 

18 (1) to any non-Federal lender. 

19 ‘‘(B) INTEREST SUBSIDIES.—In the case 

20 of a guarantee of any loan made to a rural enti21 ty under subparagraph (A), the Secretary may 

22 pay to the holder of such loan, for and on be23 half of the project for which the loan was made, 

24 amounts sufficient to reduce (by not more than 


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1 3 percent) the net effective interest rate other2 wise payable on such loan. 

3 ‘‘(b) AMOUNT OF LOAN.—The principal amount of 

4 a loan directly made or guaranteed under subsection (a) 

5 for a project for capital improvement may not exceed 

6 $5,000,000. 

7 ‘‘(c) FUNDING LIMITATIONS.— 

8 ‘‘(1) GOVERNMENT CREDIT SUBSIDY EXPO9 SURE.—The total of the Government credit subsidy 

10 exposure under the Credit Reform Act of 1990 scor11 ing protocol with respect to the loans outstanding at 

12 any time with respect to which guarantees have been 

13 issued, or which have been directly made, under sub14 section (a) may not exceed $50,000,000 per year. 

15 ‘‘(2) TOTAL AMOUNTS.—Subject to paragraph 

16 (1), the total of the principal amount of all loans di17 rectly made or guaranteed under subsection (a) may 

18 not exceed $250,000,000 per year. 

19 ‘‘(d) CAPITAL ASSESSMENT AND PLANNING

20 GRANTS.— 

21 ‘‘(1) NONREPAYABLE GRANTS.—Subject to 

22 paragraph (2), the Secretary may make a grant to 

23 a rural entity, in an amount not to exceed $50,000, 

24 for purposes of capital assessment and business 

25 planning. 


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1 ‘‘(2) LIMITATION.—The cumulative total of 

2 grants awarded under this subsection may not ex3 ceed $2,500,000 per year. 

4 ‘‘(e) TERMINATION OF AUTHORITY.—The Secretary 

5 may not directly make or guarantee any loan under sub6 section (a) or make a grant under subsection (d) after 

7 September 30, 2010.’’. 

8 (b) RURAL ENTITY DEFINED.—Section 1624 of the 

9 Public Health Service Act (42 U.S.C. 300s–3) is amended 

10 by adding at the end the following new paragraph: 

11 ‘‘(15)(A) The term ‘rural entity’ includes— 

12 ‘‘(i) a rural health clinic, as defined in sec13 tion 1861(aa)(2) of the Social Security Act; 

14 ‘‘(ii) any medical facility with at least 1 

15 bed, but with less than 50 beds, that is located 

16 in— 

17 ‘‘(I) a county that is not part of a 

18 metropolitan statistical area; or 

19 ‘‘(II) a rural census tract of a metro20 politan statistical area (as determined 

21 under the most recent modification of the 

22 Goldsmith Modification, originally pub23 lished in the Federal Register on February 

24 27, 1992 (57 Fed. Reg. 6725)); 


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1 ‘‘(iii) a hospital that is classified as a 

2 rural, regional, or national referral center under 

3 section 1886(d)(5)(C) of the Social Security 

4 Act; and 

5 ‘‘(iv) a hospital that is a sole community 

6 hospital (as defined in section 

7 1886(d)(5)(D)(iii) of the Social Security Act). 

8 ‘‘(B) For purposes of subparagraph (A), the 

9 fact that a clinic, facility, or hospital has been geo10 graphically reclassified under the Medicare program 

11 under title XVIII of the Social Security Act shall not 

12 preclude a hospital from being considered a rural en13 tity under clause (i) or (ii) of subparagraph (A).’’. 

14 (c) CONFORMING AMENDMENTS.—Section 1602 of 

15 the Public Health Service Act (42 U.S.C. 300q–2) is 

16 amended— 

17 (1) in subsection (b)(2)(D), by inserting ‘‘or 

18 1603(a)(2)(B)’’ after ‘‘1601(a)(2)(B)’’; and 

19 (2) in subsection (d)— 

20 (A) in paragraph (1)(C), by striking ‘‘sec21 tion 1601(a)(2)(B)’’ and inserting ‘‘sections 

22 1601(a)(2)(B) and 1603(a)(2)(B)’’; and 

23 (B) in paragraph (2)(A), by inserting ‘‘or 

24 1603(a)(2)(B)’’ after ‘‘1601(a)(2)(B)’’. 


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1 SEC. 9. EXTENSION OF MEDICARE INCENTIVE PAYMENT 

2 PROGRAM FOR PHYSICIAN SCARCITY AREAS. 

3 Section 1833(u)(1) of the Social Security Act (42 

4 U.S.C. 1395l(u)(1)) is amended by striking ‘‘before Janu5 ary 1, 2008’’ and inserting ‘‘before January 1, 2009’’. 

6 SEC. 10. EXTENSION OF FLOOR ON MEDICARE WORK GEO7 GRAPHIC ADJUSTMENT. 

8 Section 1848(e)(1)(E) of the Social Security Act (42 

9 U.S.C. 1395w–4(e)(1)(E)) is amended by striking ‘‘before 

10 January 1, 2007’’ and inserting ‘‘before January 1, 

11 2009’’. 

12 SEC. 11. MEDICARE HOME HEALTH CARE PLANNING IM13 PROVEMENTS. 

14 (a) IN GENERAL.—Section 1814(a)(2) of the Social 

15 Security Act (42 U.S.C. 1395f(a)(2)), in the matter pre16 ceding subparagraph (A), is amended— 

17 (1) by striking ‘‘subparagraph (B)’’ and insert18 ing ‘‘subparagraphs (B) and (C)’’; 

19 (2) by inserting ‘‘(as those terms are defined in 

20 section 1861(aa)(5))’’ after ‘‘clinical nurse spe21 cialist’’; 

22 (3) by inserting ‘‘or home health agency (as the 

23 case may be)’’ after ‘‘facility’’; and 

24 (4) by inserting ‘‘(or in the case of services de25 scribed in subparagraph (C), a physician assistant 


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1 (as defined in 1861(aa)(5)) under the supervision of 

2 a physician)’’ after ‘‘collaboration with a physician’’. 

3 (b) CONFORMING AMENDMENTS.—(1) Section 

4 1814(a) of the Social Security Act (42 U.S.C. 1395f(a)) 

5 is amended— 

6 (A) in paragraph (2)(C), by inserting ‘‘a nurse 

7 practitioner, a clinical nurse specialist, or a physi8 cian assistant (as the case may be)’’ after ‘‘physi9 cian’’ each place it appears; 

10 (B) in the second sentence, by striking ‘‘or clin11 ical nurse specialist’’ and inserting ‘‘clinical nurse 

12 specialist, or physician assistant’’; 

13 (C) in the third sentence— 

14 (i) by striking ‘‘physician certification’’ 

15 and inserting ‘‘certification’’; 

16 (ii) by inserting ‘‘(or on January 1, 2007, 

17 in the case of regulations to implement the 

18 amendments made by section 11 of the Rural 

19 Hospital and Provider Equity (HoPE) Act of 

20 2006)’’ after ‘‘1981’’; and 

21 (iii) by striking ‘‘a physician who’’ and in22 serting ‘‘a physician, nurse practitioner, clinical 

23 nurse specialist, or physician assistant who’’; 

24 and 


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1 (D) in the fourth sentence, by inserting ‘‘, 

2 nurse practitioner, clinical nurse specialist, or physi3 cian assistant’’ after ‘‘physician’’. 

4 (2) Section 1835(a) of the Social Security Act (42 

5 U.S.C. 1395n(a)) is amended— 

6 (A) in paragraph (2)— 

7 (i) in the matter preceding subparagraph 

8 (A), by inserting ‘‘or, in the case of services de9 scribed in subparagraph (A), a physician, or a 

10 nurse practitioner or clinical nurse specialist (as 

11 those terms are defined in 1861(aa)(5)), who 

12 does not have a direct or indirect employment 

13 relationship with the home health agency but is 

14 working in collaboration with a physician (or a 

15 physician assistant (as defined in 1861(aa)(5)) 

16 under the supervision of a physician)’’ after ‘‘a 

17 physician’’; and 

18 (ii) in subparagraph (A) by inserting ‘‘a 

19 nurse practitioner, a clinical nurse specialist, or 

20 a physician assistant (as the case may be)’’ 

21 after ‘‘physician’’ each place it appears; 

22 (B) in the third sentence, by inserting ‘‘, nurse 

23 practitioner, clinical nurse specialist, or physician as24 sistant (as the case may be)’’ after physician; 

25 (C) in the fourth sentence— 


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1 (i) by striking ‘‘physician certification’’ 

2 and inserting ‘‘certification’’; 

3 (ii) by inserting ‘‘(or on January 1, 2007, 

4 in the case of regulations to implement the 

5 amendments made by section 11 of the Rural 

6 Hospital and Provider Equity (HoPE) Act of 

7 2006)’’ after ‘‘1981’’; and 

8 (iii) by striking ‘‘a physician who’’ and in9 serting ‘‘a physician, nurse practitioner, clinical 

10 nurse specialist, or physician assistant who’’; 

11 and 

12 (D) in the fifth sentence, by inserting ‘‘, nurse 

13 practitioner, clinical nurse specialist, or physician as14 sistant’’ after ‘‘physician’’. 

15 (3) Section 1861 of the Social Security Act (42 

16 U.S.C. 1395x) is amended— 

17 (A) in subsection (m)— 

18 (i) in the matter preceding paragraph 

19 (1)— 

20 (I) by inserting ‘‘, or a nurse practi21 tioner, clinical nurse specialist, or physi22 cian assistant (as those terms are defined 

23 in subsection (aa)(5))’’ after ‘‘physician’’ 

24 the first place it appears; and 


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1 (II) by inserting ‘‘or a nurse practi2 tioner, clinical nurse specialist, or physi3 cian assistant’’ after ‘‘physician’’ the sec4 ond place it appears; and 

5 (ii) in paragraph (3), by inserting ‘‘or a 

6 nurse practitioner, clinical nurse specialist, or 

7 physician assistant’’ after ‘‘physician’’; and 

8 (B) in subsection (o)(2)— 

9 (i) by inserting ‘‘, nurse practitioners, clin10 ical nurse specialists, or physician assistants (as 

11 those terms are defined in subsection (aa)(5))’’ 

12 after ‘‘physicians’’; and 

13 (ii) by inserting ‘‘, nurse practitioner, clin14 ical nurse specialist, physician assistant,’’ after 

15 ‘‘physician’’ 

16 (4) Section 1895 of the Social Security Act (42 

17 U.S.C. 1395fff) is amended— 

18 (A) in subsection (c)(1), by inserting ‘‘, or the 

19 nurse practitioner, clinical nurse specialist, or physi20 cian assistant (as those terms are defined in section 

21 1861(aa)(5)),’’ after ‘‘physician’’; and 

22 (B) in subsection (e)— 

23 (i) in paragraph (1)(A), by inserting ‘‘, or 

24 a nurse practitioner, clinical nurse specialist, or 


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1 physician assistant (as those terms are defined 

2 in section 1861(aa)(5)),’’ after ‘‘physician’’; and 

3 (ii) in paragraph (2)— 

4 (I) in the heading, by striking ‘‘PHY5 SICIAN CERTIFICATION’’ and inserting 

6 ‘‘RULE OF CONSTRUCTION REGARDING RE7 QUIREMENT FOR CERTIFICATION’’; and 

8 (II) by striking ‘‘physician’’. 

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

10 this section shall apply to items and services furnished on 

11 or after January 1, 2007. 

12 SEC. 12. RURAL HEALTH CLINIC IMPROVEMENTS. 

13 Section 1833(f) of the Social Security Act (42 U.S.C. 

14 1395l(f)) is amended— 

15 (1) in paragraph (1), by striking ‘‘, and’’ at the 

16 end and inserting a semicolon; 

17 (2) in paragraph (2)— 

18 (A) by inserting ‘‘(before 2007)’’ after ‘‘in 

19 a subsequent year’’; and 

20 (B) by striking the period at the end and 

21 inserting a semicolon; and 

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

23 paragraphs: 

24 ‘‘(3) in 2007, at $82 per visit; and 


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1 ‘‘(4) in a subsequent year, at the limit estab2 lished under this subsection for the previous year in3 creased by the percentage increase in the MEI (as 

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

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

6 SEC. 13. COMMUNITY HEALTH CENTER COLLABORATIVE 

7 ACCESS EXPANSION. 

8 Section 330 of the Public Health Service Act (42 

9 U.S.C. 254b) is amended by adding at the end the fol10 lowing: 

11 ‘‘(s) MISCELLANEOUS PROVISIONS.— 

12 ‘‘(1) RULE OF CONSTRUCTION WITH RESPECT

13 TO RURAL HEALTH CLINICS.— 

14 ‘‘(A) IN GENERAL.—Nothing in this sec15 tion shall be construed to prevent a community 

16 health center from contracting with a federally 

17 certified rural health clinic (as defined by sec18 tion 1861(aa)(2) of the Social Security Act) for 

19 the delivery of primary health care services that 

20 are available at the rural health clinic to indi21 viduals who would otherwise be eligible for free 

22 or reduced cost care if that individual were able 

23 to obtain that care at the community health 

24 center. Such services may be limited in scope to 


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1 those primary health care services available in 

2 that rural health clinic. 

3 ‘‘(B) ASSURANCES.—In order for a rural 

4 health clinic to receive funds under this section 

5 through a contract with a community health 

6 center under paragraph (1), such rural health 

7 clinic shall establish policies to ensure— 

8 ‘‘(i) nondiscrimination based upon the 

9 ability of a patient to pay; and 

10 ‘‘(ii) the establishment of a sliding fee 

11 scale for low-income patients.’’. 

12 SEC. 14. APPLYING ADD-ON POLICY FOR HOME HEALTH 

13 SERVICES FURNISHED IN A RURAL AREA FOR 

14 2007. 

15 Section 421 of Medicare Prescription Drug, Improve16 ment, and Modernization Act of 2003 (Public Law 108– 

17 173; 117 Stat. 2283), as amended by section 5201(b) of 

18 the Deficit Reduction Act of 2005 (Public Law 109–171), 

19 is amended— 

20 (1) in the heading, by striking ‘‘ONE-YEAR’’ 

21 and inserting ‘‘TEMPORARY’’; and 

22 (2) in subsection (a), by striking ‘‘before Janu23 ary 1, 2007’’ and inserting ‘‘before January 1, 

24 2008’’. 


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1 SEC. 15. USE OF MEDICAL CONDITIONS FOR CODING AMBU2 LANCE SERVICES. 

3 Section 1834(l)(7) of the Social Security Act (42 

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

5 ‘‘(7) CODING SYSTEM.— 

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

7 in accordance with section 1173(c)(1)(B) and 

8 not later than January 1, 2007, establish a 

9 mandatory 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 take 

19 into account the list of medical conditions devel20 oped in the course of the negotiated rulemaking 

21 process conducted under paragraph (1).’’. 

22 SEC. 16. EXTENSION OF INCREASED MEDICARE PAYMENTS 

23 FOR GROUND AMBULANCE SERVICES IN 

24 RURAL AREAS. 

25 Section 1834(l)(13) of the Social Security Act (42 

26 U.S.C. 1395m(l)(13)) is amended— 


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1 (1) in subparagraph (A), in the matter pre2 ceding clause (i), by striking ‘‘before January 1, 

3 2007’’ and inserting ‘‘before January 1, 2008’’; 

4 (2) in subparagraph (B), in the heading, by 

5 striking ‘‘AFTER 2006’’ and inserting ‘‘AFTER 2007’’. 

6 SEC. 17. IMPROVEMENT IN PAYMENTS TO RETAIN EMER7 GENCY AND OTHER CAPACITY FOR AMBU8 LANCES IN RURAL AREAS. 

9 (a) IN GENERAL.—Section 1834(l) of the Social Se10 curity Act (42 U.S.C. 1395m(l)) is amended by adding 

11 at the end the following new paragraph: 

12 ‘‘(15) ADDITIONAL PAYMENTS FOR PROVIDERS

13 FURNISHING AMBULANCE SERVICES IN RURAL

14 AREAS.— 

15 ‘‘(A) IN GENERAL.—In the case of ground 

16 ambulance services furnished on or after Janu17 ary 1, 2007, for which the transportation origi18 nates in a rural area (as determined under sub19 paragraph (B)), the Secretary shall provide for 

20 a percent increase in the base rate of the fee 

21 schedule for a trip identified under this sub22 section. 

23 ‘‘(B) IDENTIFICATION OF RURAL AREAS.— 

24 The Secretary, in consultation with the Office 

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1 Urban Commuting Areas (RUCA) coding sys2 tem, adopted by that Office, to designate rural 

3 areas for the purposes of this paragraph. A 

4 rural area is any area in RUCA levels 2 

5 through 10 and any unclassified area. 

6 ‘‘(C) TIERING OF RURAL AREAS.—The 

7 Secretary shall designate 4 tiers of rural areas, 

8 using a ZIP Code population-based method9 ology generated by the RUCA coding system, as 

10 follows: 

11 ‘‘(i) TIER 1.—A rural area that is a 

12 high metropolitan commuting area, in 

13 which 30 percent or more of the com14 muting flow is to an urban area, as des15 ignated by the Bureau of the Census 

16 (RUCA level 2). 

17 ‘‘(ii) TIER 2.—A rural area that is a 

18 low metropolitan commuting area, in which 

19 less than 30 percent of the commuting flow 

20 is to an urban area or to a large town, as 

21 designated by the Bureau of the Census 

22 (RUCA levels 3–6). 

23 ‘‘(iii) TIER 3.—A rural area that is a 

24 small town core, as designated by the Bu25 reau of the Census, in which no significant 


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1 portion of the commuting flow is to an 

2 area of population greater than 10,000 

3 people (RUCA levels 7–9). 

4 ‘‘(iv) TIER 4.—A rural area in which 

5 there is no dominant commuting flow 

6 (RUCA level 10) and any unclassified area. 

7 The Secretary shall consult with the Office of 

8 Rural Health Policy not less often than every 2 

9 years to update the designation of rural areas 

10 in accordance with any changes that are made 

11 to the RUCA system. 

12 ‘‘(D) PAYMENT ADJUSTMENTS FOR TRIPS

13 IN RURAL AREAS.—The Secretary shall adjust 

14 the payment rate under this section for ambu15 lance trips that originate in each of the tiers es16 tablished in subparagraph (C) according to the 

17 national average cost of full-cost providers for 

18 providing ambulance services in each such 

19 tier.’’. 

20 (b) REVIEW OF PAYMENTS FOR RURAL AMBULANCE

21 SERVICES AND REPORT TO CONGRESS.— 

22 (1) REVIEW.—Not later than July 1, 2009, the 

23 Secretary of Health and Human Services shall re24 view the system for adjusting payments for rural 

25 ambulance services under section 1834(l)(15) of the 


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1 Social Security Act, as added by subsection (a), to 

2 determine the adequacy and appropriateness of such 

3 adjustments. In conducting such review, the Sec4 retary shall consult with providers and suppliers af5 fected by such adjustments and with representatives 

6 of the ambulance industry generally to determine— 

7 (A) whether such adjustments adequately 

8 cover the additional costs incurred in serving 

9 areas of low population density; and 

10 (B) whether the tiered structure for mak11 ing such adjustments appropriately reflects the 

12 difference in costs of providing services in dif13 ferent types of rural areas. 

14 (2) REPORT.—Not later than January 1, 2010, 

15 the Secretary shall submit to Congress a report on 

16 the review conducted under paragraph (1) together 

17 with any recommendations for revision to the sys18 tems for adjusting payments for ambulance services 

19 in rural areas that the Secretary of Health and 

20 Human Services determines appropriate. 

21 (c) CONFORMING AMENDMENTS.—(1) Section 

22 1834(l) of the Social Security Act (42 U.S.C. 1395m(l)), 

23 as amended by subsection (a), is amended by adding at 

24 the end the following new paragraph: 


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1 ‘‘(16) DESIGNATION OF RURAL AREAS FOR

2 MILEAGE PAYMENT PURPOSES.—In establishing any 

3 differential in the amount of payment for mileage 

4 between rural and urban areas in the fee schedule 

5 established under paragraph (1), the Secretary shall, 

6 in the case of ambulance services furnished on or 

7 after January 1, 2007, identify rural areas in the 

8 same manner as provided in paragraph (15)(B).’’. 

9 (2) Section 1834(l)(12)(A) of the Social Security Act 

10 (42 U.S.C. 1395m(l)(12)(A)) is amended by striking 

11 ‘‘January 1, 2010’’ and inserting ‘‘January 1, 2007’’. 

12 (3) Section 1834(l)(13)(A)(i) of the Social Security 

13 Act (42 U.S.C. 1395m(l)(13)(A)(i)) is amended— 

14 (A) by inserting ‘‘(or in the case of such serv15 ices furnished in 2007, in a rural area identified by 

16 the Secretary under paragraph (15)(B))’’ after 

17 ‘‘such paragraph’’; and 

18 (B) by striking ‘‘paragraphs (11) and (12)’’ 

19 and inserting ‘‘paragraphs (11), (12), and (15)’’. 

20 SEC. 18. COVERAGE OF MARRIAGE AND FAMILY THERAPIST 

21 SERVICES AND MENTAL HEALTH COUNSELOR 

22 SERVICES UNDER PART B OF THE MEDICARE 

23 PROGRAM. 

24 (a) COVERAGE OF SERVICES.— 


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1 (1) IN GENERAL.—Section 1861(s)(2) of the 

2 Social Security Act (42 U.S.C. 1395x(s)(2)), as 

3 amended by section 5112 of the Deficit Reduction 

4 Act of 2005 (Public Law 109–171), is amended— 

5 (A) in subparagraph (Z), by striking 

6 ‘‘and’’ at the end; 

7 (B) in subparagraph (AA), by inserting 

8 ‘‘and’’ at the end; and 

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

10 subparagraph: 

11 ‘‘(BB) marriage and family therapist services 

12 (as defined in subsection (ccc)(1)) and mental health 

13 counselor services (as defined in subsection 

14 (ccc)(3));’’. 

15 (2) DEFINITIONS.—Section 1861 of the Social 

16 Security Act (42 U.S.C. 1395x), as amended by sec17 tion 5112 of the Deficit Reduction Act of 2005 

18 (Public Law 109–171), is amended by adding at the 

19 end the following new subsection: 

20 ‘‘Marriage and Family Therapist Services; Marriage and 

21 Family Therapist; Mental Health Counselor Serv22 ices; Mental Health Counselor 

23 ‘‘(ccc)(1) The term ‘marriage and family therapist 

24 services’ means services performed by a marriage and 

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1 nosis and treatment of mental illnesses, which the mar2 riage and family therapist is legally authorized to perform 

3 under State law (or the State regulatory mechanism pro4 vided by State law) of the State in which such services 

5 are performed, as would otherwise be covered if furnished 

6 by a physician or as an incident to a physician’s profes7 sional service, but only if no facility or other provider 

8 charges or is paid any amounts with respect to the fur9 nishing of such services. 

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

11 an individual who— 

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

13 which qualifies for licensure or certification as a 

14 marriage and family therapist pursuant to State 

15 law; 

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

17 at least 2 years of clinical supervised experience in 

18 marriage and family therapy; and 

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

20 services in a State that provides for licensure or cer21 tification of marriage and family therapists, is li22 censed or certified as a marriage and family thera23 pist in such State. 

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

25 means services performed by a mental health counselor (as 


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

2 of mental illnesses which the mental health counselor is 

3 legally authorized to perform under State law (or the 

4 State regulatory mechanism provided by the State law) of 

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

6 otherwise be covered if furnished by a physician or as inci7 dent to a physician’s professional service, but only if no 

8 facility or other provider charges or is paid any amounts 

9 with respect to the furnishing of such services. 

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

11 individual who— 

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

13 mental health counseling or a related field; 

14 ‘‘(B) after obtaining such a degree has per15 formed at least 2 years of supervised mental health 

16 counselor practice; and 

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

18 services in a State that provides for licensure or cer19 tification of mental health counselors or professional 

20 counselors, is licensed or certified as a mental health 

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

22 (3) PROVISION FOR PAYMENT UNDER PART

23 B.—Section 1832(a)(2)(B) of the Social Security 

24 Act (42 U.S.C. 1395k(a)(2)(B)) is amended by add25 ing at the end the following new clause: 


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1 ‘‘(v) marriage and family therapist 

2 services and mental health counselor serv3 ices;’’. 

4 (4) AMOUNT OF PAYMENT.—Section 1833(a)(1) 

5 of the Social Security Act (42 U.S.C. 1395l(a)(1)) 

6 is amended— 

7 (A) by striking ‘‘and (V)’’ and inserting 

8 ‘‘(V)’’; and 

9 (B) by inserting before the semicolon at 

10 the end the following: ‘‘, and (W) with respect 

11 to marriage and family therapist services and 

12 mental health counselor services under section 

13 1861(s)(2)(BB), the amounts paid shall be 80 

14 percent of the lesser of the actual charge for 

15 the services or 75 percent of the amount deter16 mined for payment of a psychologist under sub17 paragraph (L)’’. 

18 (5) EXCLUSION OF MARRIAGE AND FAMILY

19 THERAPIST SERVICES AND MENTAL HEALTH COUN20 SELOR SERVICES FROM SKILLED NURSING FACILITY

21 PROSPECTIVE PAYMENT SYSTEM.—Section 

22 1888(e)(2)(A)(ii) of the Social Security Act (42 

23 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by inserting 

24 ‘‘marriage and family therapist services (as defined 

25 in section 1861(ccc)(1)), mental health counselor 


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1 services (as defined in section 1861(ccc)(3)),’’ after 

2 ‘‘qualified psychologist services,’’. 

3 (6) INCLUSION OF MARRIAGE AND FAMILY

4 THERAPISTS AND MENTAL HEALTH COUNSELORS AS

5 PRACTITIONERS FOR ASSIGNMENT OF CLAIMS.—Sec6 tion 1842(b)(18)(C) of the Social Security Act (42 

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

8 the end the following new clauses: 

9 ‘‘(vii) A marriage and family therapist (as de10 fined in section 1861(ccc)(2)). 

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

12 section 1861(ccc)(4)).’’. 

13 (b) COVERAGE OF CERTAIN MENTAL HEALTH SERV14 ICES PROVIDED IN CERTAIN SETTINGS.— 

15 (1) RURAL HEALTH CLINICS AND FEDERALLY

16 QUALIFIED HEALTH CENTERS.—Section 

17 1861(aa)(1)(B) of the Social Security Act (42 

18 U.S.C. 1395x(aa)(1)(B)) is amended by striking ‘‘or 

19 by a clinical social worker (as defined in subsection 

20 (hh)(1)),’’ and inserting ‘‘, by a clinical social worker 

21 (as defined in subsection (hh)(1)), by a marriage 

22 and family therapist (as defined in subsection 

23 (ccc)(2)), or by a mental health counselor (as de24 fined in subsection (ccc)(4)),’’. 


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1 (2) HOSPICE PROGRAMS.—Section 

2 1861(dd)(2)(B)(i)(III) of the Social Security Act (42 

3 U.S.C. 1395x(dd)(2)(B)(i)(III)) is amended by in4 serting ‘‘or one marriage and family therapist (as 

5 defined in subsection (ccc)(2))’’ after ‘‘social work6 er’’. 

7 (c) AUTHORIZATION OF MARRIAGE AND FAMILY

8 THERAPISTS TO DEVELOP DISCHARGE PLANS FOR POST9 HOSPITAL SERVICES.—Section 1861(ee)(2)(G) of the So10 cial Security Act (42 U.S.C. 1395x(ee)(2)(G)) is amended 

11 by inserting ‘‘marriage and family therapist (as defined 

12 in subsection (ccc)(2)),’’ after ‘‘social worker,’’. 

13 (d) EFFECTIVE DATE.—The amendments made by 

14 this section shall apply with respect to services furnished 

15 on or after January 1, 2007. 

16 SEC. 19. MEDICARE REMOTE MONITORING PILOT 

17 PROJECTS. 

18 (a) PILOT PROJECTS.— 

19 (1) IN GENERAL.—Not later than 9 months 

20 after the date of enactment of this Act, the Sec21 retary of Health and Human Services (in this sec22 tion referred to as the ‘‘Secretary’’) shall conduct 

23 pilot projects under title XVIII of the Social Secu24 rity Act for the purpose of providing incentives to 


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1 home health agencies to utilize home monitoring and 

2 communications technologies that— 

3 (A) enhance health outcomes for Medicare 

4 beneficiaries; and 

5 (B) reduce expenditures under such title. 

6 (2) SITE REQUIREMENTS.— 

7 (A) URBAN AND RURAL.—The Secretary 

8 shall conduct the pilot projects under this sec9 tion in both urban and rural areas. 

10 (B) SITE IN A SMALL STATE.—The Sec11 retary shall conduct at least 3 of the pilot 

12 projects in a State with a population of less 

13 than 1,000,000. 

14 (3) DEFINITION OF HOME HEALTH AGENCY.— 

15 In this section, the term ‘‘home health agency’’ has 

16 the meaning given that term in section 1861(o) of 

17 the Social Security Act (42 U.S.C. 1395x(o)). 

18 (b) MEDICARE BENEFICIARIES WITHIN THE SCOPE

19 OF PROJECTS.—The Secretary shall specify the criteria 

20 for identifying those Medicare beneficiaries who shall be 

21 considered within the scope of the pilot projects under this 

22 section for purposes of the application of subsection (c) 

23 and for the assessment of the effectiveness of the home 

24 health agency in achieving the objectives of this section. 

25 Such criteria may provide for the inclusion in the projects 


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1 of Medicare beneficiaries who begin receiving home health 

2 services under title XVIII of the Social Security Act after 

3 the date of the implementation of the projects. 

4 (c) INCENTIVES.— 

5 (1) PERFORMANCE TARGETS.—The Secretary 

6 shall establish for each home health agency partici7 pating in a pilot project under this section a per8 formance target using one of the following meth9 odologies, as determined appropriate by the Sec10 retary: 

11 (A) ADJUSTED HISTORICAL PERFORMANCE

12 TARGET.—The Secretary shall establish for the 

13 agency— 

14 (i) a base expenditure amount equal 

15 to the average total payments made to the 

16 agency under parts A and B of title XVIII 

17 of the Social Security Act for Medicare 

18 beneficiaries determined to be within the 

19 scope of the pilot project in a base period 

20 determined by the Secretary; and 

21 (ii) an annual per capita expenditure 

22 target for such beneficiaries, reflecting the 

23 base expenditure amount adjusted for risk 

24 and adjusted growth rates. 


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1 (B) COMPARATIVE PERFORMANCE TAR2 GET.—The Secretary shall establish for the 

3 agency a comparative performance target equal 

4 to the average total payments under such parts 

5 A and B during the pilot project for comparable 

6 individuals in the same geographic area that 

7 are not determined to be within the scope of the 

8 pilot project. 

9 (2) INCENTIVE.—Subject to paragraph (3), the 

10 Secretary shall pay to each participating home care 

11 agency an incentive payment for each year under the 

12 pilot project equal to a portion of the Medicare sav13 ings realized for such year relative to the perform14 ance target under paragraph (1). 

15 (3) LIMITATION ON EXPENDITURES.—The Sec16 retary shall limit incentive payments under this sec17 tion in order to ensure that the aggregate expendi18 tures under title XVIII of the Social Security Act 

19 (including incentive payments under this subsection) 

20 do not exceed the amount that the Secretary esti21 mates would have been expended if the pilot projects 

22 under this section had not been implemented. 

23 (d) WAIVER AUTHORITY.—The Secretary may waive 

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1 rity Act as the Secretary determines to be appropriate for 

2 the conduct of the pilot projects under this section. 

3 (e) REPORT TO CONGRESS.—Not later than 5 years 

4 after the date that the first pilot project under this section 

5 is implemented, the Secretary shall submit to Congress a 

6 report on the pilot projects. Such report shall contain a 

7 detailed description of issues related to the expansion of 

8 the projects under subsection (f) and recommendations for 

9 such legislation and administrative actions as the Sec10 retary considers appropriate. 

11 (f) EXPANSION.—If the Secretary determines that 

12 any of the pilot projects under this section enhance health 

13 outcomes for Medicare beneficiaries and reduce expendi14 tures under title XVIII of the Social Security Act, the Sec15 retary may initiate comparable projects in additional 

16 areas. 

17 (g) INCENTIVE PAYMENTS HAVE NO EFFECT ON

18 OTHER MEDICARE PAYMENTS TO AGENCIES.—An incen19 tive payment under this section— 

20 (1) shall be in addition to the payments that a 

21 home health agency would otherwise receive under 

22 title XVIII of the Social Security Act for the provi23 sion of home health services; and 

24 (2) shall have no effect on the amount of such 

25 payments. 


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1 SEC. 20. FACILITATING THE PROVISION OF TELEHEALTH 

2 SERVICES ACROSS STATE LINES. 

3 (a) IN GENERAL.—For purposes of expediting the 

4 provision of telehealth services, for which payment is made 

5 under the Medicare program, across State lines, the Sec6 retary of Health and Human Services shall, in consulta7 tion with representatives of States, physicians, health care 

8 practitioners, and patient advocates, encourage and facili9 tate the adoption of provisions allowing for multistate 

10 practitioner practice across State lines. 

11 (b) DEFINITIONS.—In subsection (a): 

12 (1) TELEHEALTH SERVICE.—The term ‘‘tele13 health service’’ has the meaning given that term in 

14 subparagraph (F) of section 1834(m)(4) of the So15 cial Security Act (42 U.S.C. 1395m(m)(4)). 

16 (2) PHYSICIAN, PRACTITIONER.—The terms 

17 ‘‘physician’’ and ‘‘practitioner’’ have the meaning 

18 given those terms in subparagraphs (D) and (E), re19 spectively, of such section. 

20 (3) MEDICARE PROGRAM.—The term ‘‘Medicare 

21 program’’ means the program of health insurance 

22 administered by the Secretary of Health and Human 

23 Services under title XVIII of the Social Security Act 

24 (42 U.S.C. 1395 et seq.). 

Æ 


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