II 

111TH CONGRESS 

1ST SESSION S. 1355 

To amend title XVIII of the Social Security Act to improve access to health 

care for individuals residing in underserved rural areas and for other 

purposes. 

IN THE SENATE OF THE UNITED STATES 

JUNE 25, 2009 

Mr. BARRASSO (for himself and Mr. WYDEN) 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 improve 

access to health care for individuals residing in underserved rural areas and for other purposes. 

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

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

5 ‘‘Rural Health Clinic Patient Access and Improvement Act 

6 of 2009’’. 

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

8 this Act is as follows: 

Sec. 1. Short title; table of contents. 

Sec. 2. Rural health clinic reimbursement. 


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Sec. 3. Rural health clinic quality reporting initiative. 

Sec. 4. Rural health clinic and community health center collaborative access expansion. 

Sec. 5. GAO report on diabetes education and medical nutrition therapy services. 

Sec. 6. Rural health clinic provider retention demonstration project. 

Sec. 7. Definition of rural health clinic. 

Sec. 8. Medicare Advantage plan payments. 

Sec. 9. Sense of the Senate regarding adequacy of network-based health plans. 

1 SEC. 2. RURAL HEALTH CLINIC REIMBURSEMENT. 

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

3 1395l(f)) is amended— 

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

5 end and inserting a semicolon; 

6 (2) in paragraph (2)— 

7 (A) by striking ‘‘in a subsequent year’’ and 

8 inserting ‘‘after 1988 and before 2010’’; and 

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

10 inserting a semicolon; and 

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

12 paragraphs: 

13 ‘‘(3) in 2010, at $92 per visit; and 

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

17 defined in section 1842(i)(3)) applicable to primary 

18 care services (as defined in section 1842(i)(4)) fur19 nished as of the first day of that year.’’. 


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1 SEC. 3. RURAL HEALTH CLINIC QUALITY REPORTING INI2 TIATIVE. 

3 Section 1833 of the Social Security Act (42 U.S.C. 

4 1395l) is amended by adding at the end the following new 

5 subsection: 

6 ‘‘(x) INCENTIVE PAYMENTS FOR RURAL HEALTH

7 CLINIC QUALITY REPORTING.— 

8 ‘‘(1) IN GENERAL.—The Secretary shall imple9 ment a system to provide incentive payments for the 

10 satisfactory reporting of data on quality measures by 

11 eligible professionals, as defined in subsection 

12 (k)(3)(B) of section 1848, who are employed by a 

13 rural health clinic or provide services in a rural 

14 health clinic through a contractual arrangement, 

15 similar to the reporting system for covered profes16 sional services as established under subsections (k) 

17 and (m) of such section. 

18 ‘‘(2) AMOUNT; DURATION.—Incentive payments 

19 in the amount of $2 per visit shall be made to rural 

20 health clinics with respect to eligible professionals 

21 who furnish rural health clinic services during the 

22 period beginning on January 1, 2010, and ending on 

23 December 31, 2013. 

24 ‘‘(3) PAYMENT FROM TRUST FUND.—The in25 centive payments provided under this subsection 

26 shall be made available from the Federal SuppleVerDate Nov 24 2008 03:39 Jun 26, 2009 Jkt 079200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S1355.IS S1355

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1 mentary Medical Insurance Trust Fund under sec2 tion 1841. 

3 ‘‘(4) PAYMENT LIMITS.—Incentive payments 

4 made under this subsection shall not be subject to 

5 the payment limits established under subsection (f). 

6 ‘‘(5) SINGLE FORM.—The Secretary shall pro7 vide rural health clinics that participate in the qual8 ity reporting system under this subsection with a 

9 single form for submission of data on quality meas10 ures and reimbursement claim information. 

11 ‘‘(6) REPORTING.—Not later than December 

12 31, 2012, the Secretary shall prepare and submit a 

13 report to Congress on the quality reporting system 

14 established under this subsection, including— 

15 ‘‘(A) the number and types of services in16 volved in the system; 

17 ‘‘(B) the number of rural health clinics 

18 participating in the system; 

19 ‘‘(C) the overall quality of care that was 

20 delivered by the rural health clinics during this 

21 period; 

22 ‘‘(D) the patient outcomes under the sys23 tem; 

24 ‘‘(E) recommendations for improving the 

25 system; and 


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1 ‘‘(F) any additional related matters that 

2 the Secretary determines appropriate.’’. 

3 SEC. 4. RURAL HEALTH CLINIC AND COMMUNITY HEALTH 

4 CENTER COLLABORATIVE ACCESS EXPAN5 SION. 

6 Section 330 of the Public Health Service Act (42 

7 U.S.C. 254b) is amended by adding at the end the fol8 lowing: 

9 ‘‘(s) RULE OF CONSTRUCTION WITH RESPECT TO

10 RURAL HEALTH CLINICS.— 

11 ‘‘(1) IN GENERAL.—Nothing in this section 

12 shall be construed to prevent a community health 

13 center from contracting with a federally certified 

14 rural health clinic (as defined by section 1861(aa)(2) 

15 of the Social Security Act) for the delivery of pri16 mary health care services that are available at the 

17 rural health clinic to individuals who would other18 wise be eligible for free or reduced cost care if that 

19 individual were able to obtain that care at the com20 munity health center. Such services may be limited 

21 in scope to those primary health care services avail22 able in that rural health clinic. 

23 ‘‘(2) ASSURANCES.—In order for a rural health 

24 clinic to receive funds under this section through a 

25 contract with a community health center under 


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1 paragraph (1), such rural health clinic shall estab2 lish policies to ensure— 

3 ‘‘(A) nondiscrimination based upon the 

4 ability of a patient to pay; and 

5 ‘‘(B) the establishment of a sliding fee 

6 scale for low-income patients.’’. 

7 SEC. 5. GAO REPORT ON DIABETES EDUCATION AND MED8 ICAL NUTRITION THERAPY SERVICES. 

9 Not later than July 1, 2012, the Comptroller General 

10 of the United States shall submit to the Committee on 

11 Health, Education, Labor, and Pensions of the Senate and 

12 the Committee on Energy and Commerce of the House 

13 of Representatives a report concerning the medical nutri14 tion therapy counseling services provided by federally 

15 qualified health clinics. Such report shall specifically ex16 amine— 

17 (1) the availability, health provider cost, reim18 bursement amount, and barriers to diabetes edu19 cation and medical nutrition therapy services in fed20 erally qualified health clinics; 

21 (2) the availability, health provider cost, reim22 bursement amount, and quality outcomes of diabetes 

23 education and medical nutrition therapy services in 

24 rural and frontier areas; 


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1 (3) the feasibility of implementing diabetes edu2 cation and medical nutrition therapy services in 

3 rural health clinics; and 

4 (4) to the extent practical, analyze existing 

5 health outcomes and cost savings attributed to dia6 betes education and medical nutrition therapy serv7 ices provided by federally qualified health centers 

8 and the potential health outcomes and cost savings 

9 if those services are offered in rural health clinics. 

10 SEC. 6. RURAL HEALTH CLINIC PROVIDER RETENTION 

11 DEMONSTRATION PROJECT. 

12 (a) IN GENERAL.—The Secretary shall establish a 

13 demonstration project under which States are awarded 

14 grants to examine whether health care professionals can 

15 be recruited or retained to work in underserved rural areas 

16 by providing such professionals with medical malpractice 

17 subsidies. 

18 (b) DURATION; SCOPE.—The demonstration project 

19 shall be conducted— 

20 (1) for a 3-year period, beginning not later than 

21 January 1, 2011; and 

22 (2) in not more than 5 States. 

23 (c) STATE APPLICATION.—A State that desires to re24 ceive a grant under the demonstration project shall submit 

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1 ner, and containing such information as the Secretary may 

2 require, including adequate assurances that the State— 

3 (1) promotes the establishment and continued 

4 maintenance of rural health clinics within the State; 

5 and 

6 (2) is working to improve access to primary 

7 care and other health care services for rural resi8 dents of the State. 

9 (d) STATE SELECTION.—In awarding grants to 

10 States under this section, the Secretary shall— 

11 (1) ensure the participation of States with a di12 verse selection of rural health clinics, including clin13 ics with 3 or less full-time equivalent physicians, 

14 physician assistants, and nurse practitioners; 

15 (2) ensure the participation of States that 

16 maintain both provider-based and independent rural 

17 health clinics; 

18 (3) give preference to States with existing 

19 State-funded medical malpractice subsidy programs; 

20 and 

21 (4) give preference to States with 15 or more 

22 rural health clinics. 

23 (e) DISTRIBUTION OF GRANT FUNDS BY STATES TO

24 RURAL HEALTH CLINICS.— 


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1 (1) IN GENERAL.—A State awarded a grant 

2 under the demonstration project shall, acting 

3 through the State Office of Rural Health, select not 

4 less than 5 rural health clinics to receive grant funds 

5 for the purpose of subsidizing medical malpractice 

6 insurance costs for health care professionals em7 ployed by such clinics. 

8 (2) RURAL HEALTH CLINIC APPLICATION.—A 

9 rural health clinic that desires to receive a grant 

10 from the State under the demonstration project shall 

11 submit to the State Office of Rural Health an appli12 cation at such time, in such manner, and containing 

13 such information as the Secretary may require, in14 cluding assurances that the clinic shall— 

15 (A) provide access to health care services 

16 for all individuals, regardless of ability to pay; 

17 (B) establish a sliding fee scale for low-in18 come patients; 

19 (C) make health care services available to 

20 individuals for not less than 20 hours per week; 

21 and 

22 (D) meet any other requirements estab23 lished by the Secretary to ensure proper and ef24 ficient use of grant funds. 


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1 (3) REQUIRED CLINIC PARTICIPATION.—A 

2 State awarded a grant under the demonstration 

3 project shall provide grant funds to at least 1 pro4 vider-based rural health clinic and at least 1 inde5 pendent rural health clinic. 

6 (4) DISTRIBUTION OF GRANT FUNDS.— 

7 (A) IN GENERAL.—Subject to paragraph 

8 (B), a State shall provide each rural health clin9 ic participating in the demonstration project 

10 with the lesser of— 

11 (i) $5,000; or 

12 (ii) 50 percent of the aggregate cost 

13 of malpractice insurance purchased by 

14 each physician, physician assistant, nurse 

15 practitioner, and certified nurse midwife 

16 (or purchased by the rural health clinic on 

17 behalf of each physician, physician assist18 ant, nurse practitioner, and certified nurse 

19 midwife) who, on a weekly basis, provides 

20 patient care services at the rural health 

21 clinic for an average of not less than— 

22 (I) 20 hours per week; or 

23 (II) 80 percent of the operational 

24 hours of the clinic. 


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1 (B) SPECIAL RULE FOR OBSTETRICS AND

2 GYNECOLOGY.—Subject to subparagraph (C), in 

3 the case of a rural health clinic participating in 

4 the demonstration project that provides obstet5 rical services, a State shall provide such clinic 

6 with the lesser of— 

7 (i) $10,000; or 

8 (ii) 50 percent of the aggregate cost 

9 of malpractice insurance purchased by 

10 each physician, physician assistant, nurse 

11 practitioner, and certified nurse midwife 

12 (or purchased by the rural health clinic on 

13 behalf of each physician, physician assist14 ant, nurse practitioner, and certified nurse 

15 midwife) who provides obstetrical services 

16 at the rural health clinic. 

17 (C) AMOUNT OF OBSTETRICAL CARE.—The 

18 Administrator of the Office of Rural Health 

19 Policy of the Health Resources and Services 

20 Administration shall develop standards for the 

21 amount of obstetrical care that a rural health 

22 clinic would have to provide in order to qualify 

23 for a grant under subparagraph (B). 

24 (f) REPORTING.— 


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1 (1) ANNUAL EVALUATIONS AND REPORTS.— 

2 The Secretary, acting through the Administrator of 

3 the Office of Rural Health Policy of the Health Re4 sources and Services Administration, shall provide 

5 for an annual evaluation of the demonstration 

6 project and submit to Congress a report on the sta7 tus of the project. 

8 (2) FINAL EVALUATION AND REPORT.—Not 

9 later than 12 months after completion of the dem10 onstration project, the Secretary, acting through the 

11 Administrator of the Office of Rural Health Policy 

12 of the Health Resources and Services Administra13 tion, shall prepare and submit to Congress a final 

14 report and evaluation of the project. The report shall 

15 include— 

16 (A) an assessment of the effectiveness of 

17 the project at recruiting and retaining health 

18 care professionals in underserved rural areas; 

19 (B) an assessment of the feasibility and ef20 ficacy of an expansion of the project to all 

21 States; and 

22 (C) an evaluation of the project in com23 parison with an expansion of coverage under 

24 chapter 171 of title 28, United States Code 

25 (commonly referred to as the ‘‘Federal Tort 


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1 Claims Act’’) to include rural health clinics as 

2 a means of recruiting and retaining health care 

3 professionals in underserved rural areas. 

4 (g) DEFINITIONS.—In this section: 

5 (1) CERTIFIED NURSE MIDWIFE.—The term 

6 ‘‘certified nurse midwife’’ has the same meaning 

7 given such term in section 1861(gg)(2) of the Social 

8 Security Act (42 U.S.C. 1395x(gg)(2)). 

9 (2) DEMONSTRATION PROJECT.—The term 

10 ‘‘demonstration project’’ means the demonstration 

11 project conducted under this section. 

12 (3) NURSE PRACTITIONER; PHYSICIAN ASSIST13 ANT; RURAL HEALTH CLINIC.—The terms ‘‘nurse 

14 practitioner’’, ‘‘physician assistant’’, and ‘‘rural 

15 health clinic’’ have the same meaning given such 

16 terms in section 1861(aa) of the Social Security Act 

17 (42 U.S.C. 1395x(aa)). 

18 (4) PHYSICIAN.—The term ‘‘physician’’ has the 

19 same meaning given such term in section 1861(r) of 

20 the Social Security Act (42 U.S.C. 1395x(r)). 

21 (5) SECRETARY.—The term ‘‘Secretary’’ means 

22 the Secretary of Health and Human Services. 

23 SEC. 7. DEFINITION OF RURAL HEALTH CLINIC. 

24 Section 1861(aa)(2) of the Social Security Act (42 

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1 serting before the last sentence the following: ‘‘A facility 

2 that is in operation, that qualifies as a rural health clinic 

3 under this title or title XIX and that subsequently fails 

4 to satisfy the requirement in clause (i) that the clinic is 

5 not located in an urbanized area, shall, with respect to 

6 services furnished on or after the date of enactment of 

7 the Rural Health Clinic Patient Access and Improvement 

8 Act of 2009, be considered, for purposes of this title and 

9 title XIX, as still satisfying such requirement if it is deter10 mined that the clinic is located in an area defined by the 

11 State and certified by the Secretary as rural.’’. 

12 SEC. 8. MEDICARE ADVANTAGE PLAN PAYMENTS. 

13 (a) IN GENERAL.—Section 1857(e) of the Social Se14 curity Act (42 U.S.C. 1395w–27(e)) is amended by adding 

15 at the end the following: 

16 ‘‘(4) MINIMUM PAYMENT RATE FOR SERVICES

17 FURNISHED BY A RURAL HEALTH CLINIC.—A con18 tract under this section between a Medicare Advan19 tage organization and the Secretary for the offering 

20 of a Medicare Advantage plan shall require the orga21 nization to provide for a payment rate under the 

22 plan for rural health clinic services furnished to en23 rollees of the plan (whether or nor the services are 

24 furnished pursuant to an agreement between the orVerDate Nov 24 2008 03:39 Jun 26, 2009 Jkt 079200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\S1355.IS S1355

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1 ganization and a rural health clinic) that is not less 

2 than— 

3 ‘‘(A) the applicable payment rate estab4 lished under part A or part B (which includes 

5 the payment of an interim rate and a subse6 quent cost reconciliation) with respect to the 

7 rural health clinic for such rural health clinic 

8 services; or 

9 ‘‘(B) if the rural health clinic determines 

10 appropriate, 103 percent of the applicable in11 terim payment rate established under part A or 

12 part B with respect to the rural health clinic for 

13 such rural health clinic services.’’. 

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

15 this section shall apply to Medicare Advantage contract 

16 years beginning on or after January 1, 2010. 

17 SEC. 9. SENSE OF THE SENATE REGARDING ADEQUACY OF 

18 NETWORK-BASED HEALTH PLANS. 

19 It is the sense of the Senate that network-based 

20 health plans shall— 

21 (1) be expected to provide a pool of health care 

22 professionals that is adequate to meet the needs of 

23 enrollees residing in rural and frontier areas; 

24 (2) ensure that enrollees residing in rural and 

25 frontier areas that have been designated by the FedVerDate Nov 24 2008 03:39 Jun 26, 2009 Jkt 079200 PO 00000 Frm 00015 Fmt 6652 Sfmt 6201 E:\BILLS\S1355.IS S1355

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1 eral Government or a State government as lacking 

2 an adequate number of health care professionals are 

3 provided with reasonable access to an in-network 

4 provider; 

5 (3) make every effort to include as part of their 

6 provider network any State-licensed or certified 

7 health care professionals (particularly primary care 

8 and mental health professionals) that are available 

9 in many underserved rural and frontier areas; and 

10 (4) recognize that reliance on a physician-only 

11 network, or forcing enrollees to travel for more than 

12 30 minutes to receive primary care or mental health 

13 services from a network provider, does not constitute 

14 an ‘‘adequate’’ network. The following distances 

15 should be used as guidelines in determining dis16 tances that correspond to a 30-minute travel time: 

17 (A) Under normal conditions with primary 

18 roads available: 20 miles. 

19 (B) In mountainous terrain or in areas 

20 with only secondary roads available: 15 miles. 

21 (C) In flat terrain or in areas connected by 

22 interstate highways: 25 miles. 

Æ 


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