II 

111TH CONGRESS 

1ST SESSION S. 1157 

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 

MAY 21, 2009 

Mr. CONRAD (for himself, Mr. ROBERTS, Mr. HARKIN, and Mr. BARRASSO) 

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 ‘‘Craig Thomas Rural Hospital and Provider Equity Act 

6 of 2009’’. 

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

8 this Act is as follows: 


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Sec. 1. Short title; table of contents. 

Sec. 2. Fairness in the Medicare disproportionate share hospital (DSH) adjustment for rural hospitals. 

Sec. 3. Revision of the 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 and temporary improvements to the Medicare inpatient hospital payment adjustment for low-volume hospitals. 

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. Elimination of isolation test for cost-based ambulance reimbursement 

for critical access hospitals. 

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. Permitting physician assistants to order post-hospital extended care 

services; permitting physician assistants when delegated by a 

physician to order hospice care; improving care planning for 

Medicare home health services. 

Sec. 12. Rural health clinic improvements. 

Sec. 13. Community health center collaborative access expansion. 

Sec. 14. Application of the temporary Medicare payment increase for home 

health services furnished in a rural area to 2010. 

Sec. 15. Extension of increased Medicare payments for rural ground ambulance 

services. 

Sec. 16. Coverage of marriage and family therapist services and mental health 

counselor services under Part B of the Medicare program. 

Sec. 17. Extension of treatment of certain physician pathology services under 

Medicare. 

Sec. 18. Medicare remote monitoring pilot projects. 

Sec. 19. Facilitating the provision of telehealth services across State lines. 

Sec. 20. Medicare Part A payment for anesthesiologist services in certain rural 

hospitals based on CRNA pass-through rules. 

Sec. 21. Temporary floor on the practice expense geographic index for services 

furnished in rural areas under the Medicare physician fee 

schedule. 

Sec. 22. Temporary floor on Medicare hospital area wage index for certain hospitals. 

Sec. 23. Revisions to standard for designation of sole community hospitals. 

1 SEC. 2. FAIRNESS IN THE MEDICARE DISPROPORTIONATE 

2 SHARE HOSPITAL (DSH) ADJUSTMENT FOR 

3 RURAL HOSPITALS. 

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

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


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

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

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

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

5 any hospital with respect to discharges occurring on 

6 or after October 1, 2010.’’. 

7 SEC. 3. REVISION OF THE MEDICARE HOLD HARMLESS 

8 PROVISION UNDER THE PROSPECTIVE PAY9 MENT SYSTEM FOR HOSPITAL OUTPATIENT 

10 DEPARTMENT (HOPD) SERVICES. 

11 Section 1833(t)(7)(D)(i) of the Social Security Act 

12 (42 U.S.C. 1395l(t)(7)(D)(i)) is amended— 

13 (1) in subclause (II)— 

14 (A) by striking ‘‘2010’’ and inserting 

15 ‘‘2011’’; 

16 (B) by striking ‘‘and 85’’ and inserting 

17 ‘‘85’’; and 

18 (C) in the second sentence, by inserting ‘‘, 

19 and 100 percent with respect to such services 

20 furnished in 2010’’ before the period at the 

21 end; and 

22 (2) in subclause (III)— 

23 (A) by striking ‘‘2010’’ and inserting 

24 ‘‘2011’’; 


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1 (B) by striking ‘‘85 percent’’ and inserting 

2 ‘‘the applicable percentage’’; and 

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

4 sentence: ‘‘For purposes of the preceding sen5 tence, the applicable percentage shall be 85 per6 cent with respect to covered OPD services fur7 nished in 2009 and 100 percent for such serv8 ices furnished in 2010.’’ 

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

10 HOSPITAL FOR PURPOSES OF THE MEDICARE 

11 INPATIENT HOSPITAL PAYMENT ADJUST12 MENT AND TEMPORARY IMPROVEMENTS TO 

13 THE MEDICARE INPATIENT HOSPITAL PAY14 MENT ADJUSTMENT FOR LOW-VOLUME HOS15 PITALS. 

16 (a) IMPROVEMENT OF DEFINITION OF LOW-VOLUME

17 HOSPITAL FOR PURPOSES OF THE MEDICARE INPATIENT

18 HOSPITAL PAYMENT ADJUSTMENT.—Section 

19 1886(d)(12)(C)(i) of the Social Security Act (42 U.S.C. 

20 1395ww(d)(12)(C)(i)) is amended by inserting ‘‘(or, be21 ginning with fiscal year 2010, 2,000 discharges)’’ after 

22 ‘‘800 discharges’’. 

23 (b) TEMPORARY IMPROVEMENTS TO THE MEDICARE

24 INPATIENT HOSPITAL PAYMENT ADJUSTMENT FOR LOW25 VOLUME HOSPITALS.—Section 1886(d)(12) of the Social 


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1 Security Act (42 U.S.C. 1395ww(d)(12)), as amended by 

2 subsection (a), is amended— 

3 (1) in subparagraph (A), by inserting ‘‘or (D)’’ 

4 after ‘‘subparagraph (B)’’; 

5 (2) in subparagraph (B), by striking ‘‘The Sec6 retary’’ and inserting ‘‘For discharges occurring in 

7 fiscal years 2005 through 2009 and for discharges 

8 occurring in fiscal year 2012 and subsequent fiscal 

9 years, the Secretary’’; 

10 (3) in subparagraph (C)(i), by inserting ‘‘(or, 

11 with respect to fiscal years 2010 and 2011, 15 road 

12 miles)’’ after ‘‘25 road miles’’; and 

13 (4) by adding at the end the following new sub14 paragraph: 

15 ‘‘(D) TEMPORARY APPLICABLE PERCENT16 AGE INCREASE.—For discharges occurring in 

17 fiscal years 2010 or 2011, the Secretary shall 

18 determine an applicable percentage increase for 

19 purposes of subparagraph (A) using a linear 

20 sliding scale ranging from 25 percent for low21 volume hospitals with fewer than an appro22 priate number (as determined by the Secretary) 

23 of discharges of individuals entitled to, or en24 rolled for, benefits under part A in the fiscal 

25 year to 0 percent for low-volume hospitals with 


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1 greater than 2,000 discharges of such individ2 uals in the fiscal year.’’. 

3 SEC. 5. EXTENSION OF MEDICARE WAGE INDEX RECLASSI4 FICATIONS FOR CERTAIN HOSPITALS. 

5 (a) EXTENSION OF CORRECTION OF MID-YEAR RE6 CLASSIFICATION EXPIRATION FOR CERTAIN HOS7 PITALS.— 

8 (1) IN GENERAL.—In the case of a hospital de9 scribed in paragraph (2), effective September 30, 

10 2009, the Secretary of Health and Human Services 

11 shall apply subsection (a) of section 106 of division 

12 B of the Tax Relief and Health Care Act of 2006 

13 (42 U.S.C. 1395ww note), as amended by section 

14 124(a) of the Medicare Improvements for Patients 

15 and Providers Act of 2008 (Public Law 110–275) by 

16 substituting ‘‘September 30, 2010’’ for ‘‘September 

17 30, 2009’’. 

18 (2) HOSPITAL DESCRIBED.—A hospital de19 scribed in this paragraph is a hospital— 

20 (A) that is described in subsection (a) of 

21 such section 106; and 

22 (B)(i) that is located in a rural area; and 

23 (ii) for which the Secretary of Health and 

24 Human Services has determined the extension 

25 under this subsection to be appropriate. 


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1 (b) ADDITIONAL EXTENSION.—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)) under section 117(a)(2) of the Medi10 care, Medicaid, and SCHIP Extension Act of 2007 (Public 

11 Law 110–173), as amended by section 124(b) of the Medi12 care Improvements for Patients and Providers Act of 2008 

13 (Public Law 110–275), through September 30, 2010. 

14 (c) NOT BUDGET NEUTRAL.—The provisions of this 

15 section shall not be effected in a budget-neutral manner. 

16 SEC. 6. EXTENSION OF MEDICARE REASONABLE COSTS 

17 PAYMENTS FOR CERTAIN CLINICAL DIAG18 NOSTIC LABORATORY TESTS FURNISHED TO 

19 HOSPITAL PATIENTS IN CERTAIN RURAL 

20 AREAS. 

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

22 Improvement, and Modernization Act of 2003 (42 U.S.C. 

23 1395l–4(b)), as amended by section 107 of the Medicare, 

24 Medicaid, and SCHIP Extension Act of 2007 (Public Law 

25 110–173), is amended by inserting ‘‘, or, beginning during 


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1 the period beginning on July 1, 2010, and ending on June 

2 30, 2011’’ after ‘‘2008’’. 

3 SEC. 7. ELIMINATION OF ISOLATION TEST FOR COST-BASED 

4 AMBULANCE REIMBURSEMENT FOR CRIT5 ICAL ACCESS HOSPITALS. 

6 (a) IN GENERAL.—Section 1834(l)(8) of the Social 

7 Security Act (42 U.S.C. 1395m(l)(8)) is amended— 

8 (1) in subparagraph (B)— 

9 (A) by striking ‘‘owned and’’; and 

10 (B) by inserting ‘‘(including when such 

11 services are provided by the entity under an ar12 rangement with the hospital)’’ after ‘‘hospital’’; 

13 and 

14 (2) by striking the comma at the end of sub15 paragraph (B) and all that follows and inserting a 

16 period. 

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

18 this section shall apply to services furnished on or after 

19 January 1, 2010. 

20 SEC. 8. CAPITAL INFRASTRUCTURE REVOLVING LOAN PRO21 GRAM. 

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

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

24 by adding at the end the following new section: 


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1 ‘‘CAPITAL INFRASTRUCTURE REVOLVING LOAN PROGRAM

2 ‘‘SEC. 1603. (a) AUTHORITY TO MAKE AND GUAR3 ANTEE LOANS.— 

4 ‘‘(1) AUTHORITY TO MAKE LOANS.—The Sec5 retary may make loans from the fund established 

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

7 projects for capital improvements, including— 

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

9 the capital improvements; 

10 ‘‘(B) the renovation or modernization of 

11 any building; 

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

13 major movable equipment; and 

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

15 Secretary determines appropriate. 

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

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

18 guarantee the payment of principal and interest 

19 for loans made to rural entities for projects for 

20 any capital improvement described in paragraph 

21 (1) to any non-Federal lender. 

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

23 of a guarantee of any loan made to a rural enti24 ty under subparagraph (A), the Secretary may 

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1 half of the project for which the loan was made, 

2 amounts sufficient to reduce (by not more than 

3 3 percent) the net effective interest rate other4 wise payable on such loan. 

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

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

7 for a project for capital improvement may not exceed 

8 $5,000,000. 

9 ‘‘(c) FUNDING LIMITATIONS.— 

10 ‘‘(1) GOVERNMENT CREDIT SUBSIDY EXPO11 SURE.—The total of the Government credit subsidy 

12 exposure under the Credit Reform Act of 1990 scor13 ing protocol with respect to the loans outstanding at 

14 any time with respect to which guarantees have been 

15 issued, or which have been directly made, under sub16 section (a) may not exceed $50,000,000 per year. 

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

18 (1), the total of the principal amount of all loans di19 rectly made or guaranteed under subsection (a) may 

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

21 ‘‘(d) CAPITAL ASSESSMENT AND PLANNING

22 GRANTS.— 

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

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

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


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1 for purposes of capital assessment and business 

2 planning. 

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

4 grants awarded under this subsection may not ex5 ceed $2,500,000 per year. 

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

7 may not directly make or guarantee any loan under sub8 section (a) or make a grant under subsection (d) after 

9 September 30, 2013.’’. 

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

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

12 by adding at the end the following new paragraph: 

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

14 ‘‘(i) a rural health clinic, as defined in sec15 tion 1861(aa)(2) of the Social Security Act; 

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

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

18 in— 

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

20 metropolitan statistical area; or 

21 ‘‘(II) a rural census tract of a metro22 politan statistical area (as determined 

23 under the most recent modification of the 

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1 lished in the Federal Register on February 

2 27, 1992 (57 Fed. Reg. 6725)); 

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

4 rural, regional, or national referral center under 

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

6 Act; and 

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

8 hospital (as defined in section 

9 1886(d)(5)(D)(iii) of the Social Security Act). 

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

11 fact that a clinic, facility, or hospital has been geo12 graphically reclassified under the Medicare program 

13 under title XVIII of the Social Security Act shall not 

14 preclude a hospital from being considered a rural en15 tity under clause (i) or (ii) of subparagraph (A).’’. 

16 (c) CONFORMING AMENDMENTS.—Section 1602 of 

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

18 amended— 

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

20 1603(a)(2)(B)’’ after ‘‘1601(a)(2)(B)’’; and 

21 (2) in subsection (d)— 

22 (A) in paragraph (1)(C), by striking ‘‘sec23 tion 1601(a)(2)(B)’’ and inserting ‘‘sections 

24 1601(a)(2)(B) and 1603(a)(2)(B)’’; and 


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

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

3 SEC. 9. EXTENSION OF MEDICARE INCENTIVE PAYMENT 

4 PROGRAM FOR PHYSICIAN SCARCITY AREAS. 

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

6 U.S.C. 1395l(u)(1)) is amended by inserting ‘‘, and such 

7 services furnished on or after January 1, 2010, and before 

8 July 1, 2011’’ after ‘‘2008’’. 

9 SEC. 10. EXTENSION OF FLOOR ON MEDICARE WORK GEO10 GRAPHIC ADJUSTMENT. 

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

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

13 January 1, 2010’’ and inserting ‘‘before January 1, 

14 2011’’. 

15 SEC. 11. PERMITTING PHYSICIAN ASSISTANTS TO ORDER 

16 POST-HOSPITAL EXTENDED CARE SERVICES; 

17 PERMITTING PHYSICIAN ASSISTANTS WHEN 

18 DELEGATED BY A PHYSICIAN TO ORDER HOS19 PICE CARE; IMPROVING CARE PLANNING FOR 

20 MEDICARE HOME HEALTH SERVICES. 

21 (a) PERMITTING PHYSICIAN ASSISTANTS TO ORDER

22 POST-HOSPITAL EXTENDED CARE SERVICES AND TO

23 PROVIDE FOR RECOGNITION OF ATTENDING PHYSICIAN

24 ASSISTANTS AS ATTENDING PHYSICIANS TO SERVE HOS25 PICE PATIENTS.— 


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1 (1) ORDERING POST-HOSPITAL EXTENDED

2 CARE SERVICES.— 

3 (A) IN GENERAL.—Section 1814(a)(2) of 

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

5 1395f(a)(2)), in the matter preceding subpara6 graph (A), is amended by striking ‘‘nurse prac7 titioner or clinical nurse specialist’’ and insert8 ing ‘‘nurse practitioner, a clinical nurse spe9 cialist, or a physician assistant (as those terms 

10 are defined in section 1861(aa)(5))’’. 

11 (B) CONFORMING AMENDMENT.—Section 

12 1814(a) of the Social Security Act (42 U.S.C. 

13 1395f(a)) is amended, in the second sentence, 

14 by striking ‘‘or clinical nurse specialist’’ and in15 serting ‘‘clinical nurse specialist, or physician 

16 assistant’’. 

17 (2) RECOGNITION OF ATTENDING PHYSICIAN

18 ASSISTANTS AS ATTENDING PHYSICIANS TO SERVE

19 HOSPICE PATIENTS.— 

20 (A) IN GENERAL.—Section 1861(dd)(3)(B) 

21 of the Social Security Act (42 U.S.C. 

22 1395x(dd)(3)(B)) is amended— 

23 (i) by striking ‘‘or nurse’’ and insert24 ing ‘‘, the nurse’’; and 


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1 (ii) by inserting ‘‘, or the physician 

2 assistant (as defined in such subsection)’’ 

3 after ‘‘subsection (aa)(5))’’. 

4 (B) PERMITTING PHYSICIAN ASSISTANTS

5 WHEN DELEGATED BY A PHYSICIAN TO ORDER

6 HOSPICE CARE.—Section 1814(a)(7)(A) of such 

7 Act (42 U.S.C. 1395f(a)(7)(A)) is amended— 

8 (i) in clause (i)(I), by inserting ‘‘or a 

9 physician assistant as delegated by such 

10 attending physician’’ after ‘‘nurse practi11 tioner)’’; and 

12 (ii) in clause (ii), by inserting ‘‘or 

13 physician assistant’’ after ‘‘physician’’. 

14 (b) IMPROVING CARE PLANNING FOR MEDICARE

15 HOME HEALTH SERVICES.— 

16 (1) IN GENERAL.—Section 1814(a)(2) of the 

17 Social Security Act (42 U.S.C. 1395f(a)(2)), in the 

18 matter preceding subparagraph (A), is amended by 

19 inserting ‘‘, or in the case of services described in 

20 subparagraph (C), a physician, or a nurse practi21 tioner or clinical nurse specialist who is working in 

22 collaboration with a physician in accordance with 

23 State law, or a certified nurse-midwife (as defined in 

24 section 1861(gg)) as authorized by State law, or a 

25 physician assistant (as defined in section 


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1 1861(aa)(5)) under the supervision of a physician’’ 

2 after ‘‘collaboration with a physician’’. 

3 (2) CONFORMING AMENDMENTS.—(A) Section 

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

5 1395f(a)), as amended by subsection (a), is amend6 ed— 

7 (i) in paragraph (2)(C), by inserting ‘‘, a 

8 nurse practitioner, a clinical nurse specialist, a 

9 certified nurse-midwife, or a physician assistant 

10 (as the case may be)’’ after ‘‘physician’’ each 

11 place it appears; 

12 (ii) in the second sentence, by striking 

13 ‘‘clinical nurse specialist, or physician assist14 ant’’ and inserting ‘‘clinical nurse specialist, 

15 certified nurse-midwife, or physician assistant’’; 

16 (iii) in the third sentence— 

17 (I) by striking ‘‘physician certifi18 cation’’ and inserting ‘‘certification’’; 

19 (II) by inserting ‘‘(or on January 1, 

20 2010, in the case of regulations to imple21 ment the amendments made by section 11 

22 of the Craig Thomas Rural Hospital and 

23 Provider Equity Act of 2009)’’ after 

24 ‘‘1981’’; and 


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1 (III) by striking ‘‘a physician who’’ 

2 and inserting ‘‘a physician, nurse practi3 tioner, clinical nurse specialist, certified 

4 nurse-midwife, or physician assistant 

5 who’’; and 

6 (iv) in the fourth sentence, by inserting ‘‘, 

7 nurse practitioner, clinical nurse specialist, cer8 tified nurse-midwife, or physician assistant’’ 

9 after ‘‘physician’’. 

10 (B) Section 1835(a) of the Social Security Act 

11 (42 U.S.C. 1395n(a)) is amended— 

12 (i) in paragraph (2)— 

13 (I) in the matter preceding subpara14 graph (A), by inserting ‘‘or, in the case of 

15 services described in subparagraph (A), a 

16 physician, or a nurse practitioner or clin17 ical nurse specialist (as those terms are de18 fined in 1861(aa)(5)) who is working in 

19 collaboration with a physician in accord20 ance with State law, or a certified nurse21 midwife (as defined in section 1861(gg)) as 

22 authorized by State law, or a physician as23 sistant (as defined in section 1861(aa)(5)) 

24 under the supervision of a physician’’ after 

25 ‘‘a physician’’; and 


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1 (II) in each of clauses (ii) and (iii) of 

2 subparagraph (A) by inserting ‘‘, a nurse 

3 practitioner, a clinical nurse specialist, a 

4 certified nurse-midwife, or a physician as5 sistant (as the case may be)’’ after ‘‘physi6 cian’’; 

7 (ii) in the third sentence, by inserting ‘‘, 

8 nurse practitioner, clinical nurse specialist, cer9 tified nurse-midwife, or physician assistant (as 

10 the case may be)’’ after physician; 

11 (iii) in the fourth sentence— 

12 (I) by striking ‘‘physician certifi13 cation’’ and inserting ‘‘certification’’; 

14 (II) by inserting ‘‘(or on January 1, 

15 2010, in the case of regulations to imple16 ment the amendments made by section 11 

17 of the Craig Thomas Rural Hospital and 

18 Provider Equity Act of 2009)’’ after 

19 ‘‘1981’’; and 

20 (III) by striking ‘‘a physician who’’ 

21 and inserting ‘‘a physician, nurse practi22 tioner, clinical nurse specialist, certified 

23 nurse-midwife, or physician assistant 

24 who’’; and 


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1 (iv) in the fifth sentence, by inserting ‘‘, 

2 nurse practitioner, clinical nurse specialist, cer3 tified nurse-midwife, or physician assistant’’ 

4 after ‘‘physician’’. 

5 (C) Section 1861 of the Social Security Act (42 

6 U.S.C. 1395x) is amended— 

7 (i) in subsection (m)— 

8 (I) in the matter preceding paragraph 

9 (1)— 

10 (aa) by inserting ‘‘a nurse practi11 tioner or a clinical nurse specialist (as 

12 those terms are defined in subsection 

13 (aa)(5)), a certified nurse-midwife (as 

14 defined in section 1861(gg)), or a 

15 physician assistant (as defined in sub16 section (aa)(5))’’ after ‘‘physician’’ 

17 the first place it appears; and 

18 (bb) by inserting ‘‘a nurse practi19 tioner, a clinical nurse specialist, a 

20 certified nurse-midwife, or a physician 

21 assistant’’ after ‘‘physician’’ the sec22 ond place it appears; and 

23 (II) in paragraph (3), by inserting ‘‘a 

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1 cialist, a certified nurse-midwife, or a phy2 sician assistant’’ after ‘‘physician’’; and 

3 (ii) in subsection (o)(2)— 

4 (I) by inserting ‘‘, nurse practitioners 

5 or clinical nurse specialists (as those terms 

6 are defined in subsection (aa)(5)), certified 

7 nurse-midwives (as defined in section 

8 1861(gg)), or physician assistants (as de9 fined in subsection (aa)(5))’’ after ‘‘physi10 cians’’; and 

11 (II) by inserting ‘‘, nurse practitioner, 

12 clinical nurse specialist, certified nurse13 midwife, physician assistant,’’ after ‘‘physi14 cian’’. 

15 (D) Section 1895 of the Social Security Act (42 

16 U.S.C. 1395fff) is amended— 

17 (i) in subsection (c)(1), by inserting ‘‘, the 

18 nurse practitioner or clinical nurse specialist (as 

19 those terms are defined in section 1861(aa)(5)), 

20 the certified nurse-midwife (as defined in sec21 tion 1861(gg)), or the physician assistant (as 

22 defined in section 1861(aa)(5)),’’ after ‘‘physi23 cian’’; and 

24 (ii) in subsection (e)— 


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1 (I) in paragraph (1)(A), by inserting 

2 ‘‘, a nurse practitioner or clinical nurse 

3 specialist (as those terms are defined in 

4 section 1861(aa)(5)), a certified nurse-mid5 wife (as defined in section 1861(gg)), or a 

6 physician assistant (as defined in section 

7 1861(aa)(5))’’ after ‘‘physician’’; and 

8 (II) in paragraph (2)— 

9 (aa) in the heading, by striking 

10 ‘‘PHYSICIAN CERTIFICATION’’ and in11 serting ‘‘RULE OF CONSTRUCTION RE12 GARDING REQUIREMENT FOR CERTIFI13 CATION’’; and 

14 (bb) by striking ‘‘physician’’. 

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

16 this section shall apply to items and services furnished on 

17 or after January 1, 2010. 

18 SEC. 12. RURAL HEALTH CLINIC IMPROVEMENTS. 

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

20 1395l(f)) is amended— 

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

22 end and inserting a semicolon; 

23 (2) in paragraph (2)— 

24 (A) by inserting ‘‘(before 2010)’’ after ‘‘in 

25 a subsequent year’’; and 


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

2 inserting a semicolon; and 

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

4 paragraphs: 

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

6 ‘‘(4) in a subsequent year, at the limit estab7 lished under this subsection for the previous year in8 creased by the percentage increase in the MEI (as 

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

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

11 SEC. 13. COMMUNITY HEALTH CENTER COLLABORATIVE 

12 ACCESS EXPANSION. 

13 Section 330 of the Public Health Service Act (42 

14 U.S.C. 254b) is amended by adding at the end the fol15 lowing: 

16 ‘‘(s) MISCELLANEOUS PROVISIONS.— 

17 ‘‘(1) RULE OF CONSTRUCTION WITH RESPECT

18 TO RURAL HEALTH CLINICS.— 

19 ‘‘(A) IN GENERAL.—Nothing in this sec20 tion shall be construed to prevent a community 

21 health center from contracting with a federally 

22 certified rural health clinic (as defined by sec23 tion 1861(aa)(2) of the Social Security Act) for 

24 the delivery of primary health care services that 

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1 viduals who would otherwise be eligible for free 

2 or reduced cost care if that individual were able 

3 to obtain that care at the community health 

4 center. Such services may be limited in scope to 

5 those primary health care services available in 

6 that rural health clinic. 

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

8 health clinic to receive funds under this section 

9 through a contract with a community health 

10 center under paragraph (1), such rural health 

11 clinic shall establish policies to ensure— 

12 ‘‘(i) nondiscrimination based upon the 

13 ability of a patient to pay; and 

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

15 scale for low-income patients.’’. 

16 SEC. 14. APPLICATION OF THE TEMPORARY MEDICARE 

17 PAYMENT INCREASE FOR HOME HEALTH 

18 SERVICES FURNISHED IN A RURAL AREA TO 

19 2010. 

20 Section 421 of the Medicare Prescription Drug, Im21 provement, and Modernization Act of 2003 (42 U.S.C. 

22 1395fff note), as amended by section 5201(b) of the Def23 icit Reduction Act of 2005 (42 U.S.C. 1395fff note), is 

24 amended— 


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1 (1) in the section heading, by striking ‘‘ONE2 YEAR’’ and inserting ‘‘TEMPORARY’’; and 

3 (2) in subsection (a), by inserting ‘‘and episodes 

4 and visits ending on or after January 1, 2010, and 

5 before January 1, 2011,’’ after ‘‘January 1, 2007,’’. 

6 SEC. 15. EXTENSION OF INCREASED MEDICARE PAYMENTS 

7 FOR RURAL GROUND AMBULANCE SERVICES. 

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

9 U.S.C. 1395m(l)(13)) is amended— 

10 (1) in subparagraph (A), in the heading, by 

11 striking ‘‘IN GENERAL’’ and inserting ‘‘FOR THE

12 SECOND HALF OF 2004 AND FOR 2005, 2006, THE

13 SECOND HALF OF 2008, AND 2009’’; 

14 (2) by redesignating subparagraph (B) as sub15 paragraph (C); 

16 (3) by inserting the following after subpara17 graph (A): 

18 ‘‘(B) FOR 2010 AND 2011 FOR RURAL

19 AREAS.—After computing the rates with respect 

20 to ground ambulance services under the other 

21 applicable provisions of this subsection, in the 

22 case of such services furnished on or after Jan23 uary 1, 2010, and before January 1, 2012, for 

24 which the transportation originates in a rural 

25 area described in paragraph (9) or in a rural 


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1 census tract described in such paragraph, the 

2 fee schedule established under this section shall 

3 provide that the rate for the service otherwise 

4 established, after application of any increase 

5 under paragraphs (11) and (12), shall be in6 creased by 5 percent.’’; and 

7 (4) in subparagraph (C), as redesignated by 

8 paragraph (2)— 

9 (A) in the heading, by striking ‘‘APPLICA10 TION OF INCREASED PAYMENTS AFTER APPLI11 CABLE PERIOD’’ and inserting ‘‘NO EFFECT ON

12 SUBSEQUENT PERIODS’’; and 

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

14 sentence: ‘‘The increased payments under sub15 paragraph (B) shall not be taken into account 

16 in calculating payments for services furnished 

17 after the period specified in such subpara18 graph.’’. 

19 SEC. 16. COVERAGE OF MARRIAGE AND FAMILY THERAPIST 

20 SERVICES AND MENTAL HEALTH COUNSELOR 

21 SERVICES UNDER PART B OF THE MEDICARE 

22 PROGRAM. 

23 (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)) is 

3 amended— 

4 (A) in subparagraph (DD), by striking 

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

6 (B) in subparagraph (EE), by inserting 

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

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

9 subparagraph: 

10 ‘‘(FF) marriage and family therapist services 

11 (as defined in subsection (hhh)(1)) and mental 

12 health counselor services (as defined in subsection 

13 (hhh)(3));’’. 

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

15 Security Act (42 U.S.C. 1395x) is amended by add16 ing at the end the following new subsection: 

17 ‘‘Marriage and Family Therapist Services; Marriage and 

18 Family Therapist; Mental Health Counselor Serv19 ices; Mental Health Counselor 

20 ‘‘(hhh)(1) The term ‘marriage and family therapist 

21 services’ means services performed by a marriage and 

22 family therapist (as defined in paragraph (2)) for the diag23 nosis and treatment of mental illnesses, which the mar24 riage and family therapist is legally authorized to perform 

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1 vided by State law) of the State in which such services 

2 are performed, as would otherwise be covered if furnished 

3 by a physician or as an incident to a physician’s profes4 sional service, but only if no facility or other provider 

5 charges or is paid any amounts with respect to the fur6 nishing of such services. 

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

8 an individual who— 

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

10 which qualifies for licensure or certification as a 

11 marriage and family therapist pursuant to State 

12 law; 

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

14 at least 2 years of clinical supervised experience in 

15 marriage and family therapy; and 

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

17 services in a State that provides for licensure or cer18 tification of marriage and family therapists, is li19 censed or certified as a marriage and family thera20 pist in such State. 

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

22 means services performed by a mental health counselor (as 

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

24 of mental illnesses which the mental health counselor is 

25 legally authorized to perform under State law (or the 


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1 State regulatory mechanism provided by the State law) of 

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

3 otherwise be covered if furnished by a physician or as inci4 dent to a physician’s professional service, but only if no 

5 facility or other provider charges or is paid any amounts 

6 with respect to the furnishing of such services. 

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

8 individual who— 

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

10 mental health counseling or a related field; 

11 ‘‘(B) after obtaining such a degree has per12 formed at least 2 years of supervised mental health 

13 counselor practice; and 

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

15 services in a State that provides for licensure or cer16 tification of mental health counselors or professional 

17 counselors, is licensed or certified as a mental health 

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

19 (3) PROVISION FOR PAYMENT UNDER PART

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

21 Act (42 U.S.C. 1395k(a)(2)(B)) is amended by add22 ing at the end the following new clause: 

23 ‘‘(v) marriage and family therapist 

24 services (as defined in section 

25 1861(hhh)(1)) and mental health counselor 


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1 services (as defined in section 

2 1861(hhh)(3));’’. 

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

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

5 is amended— 

6 (A) by striking ‘‘and (W)’’ and inserting 

7 ‘‘(W)’’; and 

8 (B) by inserting before the semicolon at 

9 the end the following: ‘‘, and (X) with respect 

10 to marriage and family therapist services and 

11 mental health counselor services under section 

12 1861(s)(2)(BB), the amounts paid shall be 80 

13 percent of the lesser of the actual charge for 

14 the services or 75 percent of the amount deter15 mined for payment of a psychologist under sub16 paragraph (L)’’. 

17 (5) EXCLUSION OF MARRIAGE AND FAMILY

18 THERAPIST SERVICES AND MENTAL HEALTH COUN19 SELOR SERVICES FROM SKILLED NURSING FACILITY

20 PROSPECTIVE PAYMENT SYSTEM.—Section 

21 1888(e)(2)(A)(ii) of the Social Security Act (42 

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

23 ‘‘marriage and family therapist services (as defined 

24 in section 1861(hhh)(1)), mental health counselor 


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1 services (as defined in section 1861(hhh)(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(hhh)(2)). 

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

12 section 1861(hhh)(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 (hhh)(2)), or by a mental health counselor (as de24 fined in subsection (hhh)(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 ‘‘, marriage and family therapist, or mental 

5 health counselor’’ after ‘‘social worker’’. 

6 (c) AUTHORIZATION OF MARRIAGE AND FAMILY

7 THERAPISTS AND MENTAL HEALTH COUNSELORS TO

8 DEVELOP DISCHARGE PLANS FOR POST-HOSPITAL SERV9 ICES.—Section 1861(ee)(2)(G) of the Social Security Act 

10 (42 U.S.C. 1395x(ee)(2)(G)) is amended by inserting ‘‘, 

11 including a marriage and family therapist and a mental 

12 health counselor who meets qualification standards estab13 lished by the Secretary’’ before the period at the end. 

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

15 this section shall apply with respect to services furnished 

16 on or after January 1, 2010. 

17 SEC. 17. EXTENSION OF TREATMENT OF CERTAIN PHYSI18 CIAN PATHOLOGY SERVICES UNDER MEDI19 CARE. 

20 Section 542(c) of the Medicare, Medicaid, and 

21 SCHIP Benefits Improvement and Protection Act of 2000 

22 (as enacted into law by section 1(a)(6) of Public Law 106– 

23 554), as amended by section 732 of the Medicare Prescrip24 tion Drug, Improvement, and Modernization Act of 2003 

25 (42 U.S.C. 1395w–4 note), section 104 of division B of 


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1 the Tax Relief and Health Care Act of 2006 (42 U.S.C. 

2 1395w–4 note), section 104 of the Medicare, Medicaid, 

3 and SCHIP Extension Act of 2007 (Public Law 110– 

4 173), and section 136 of the Medicare Improvements for 

5 Patients and Providers Act of 2008 (Public Law 110– 

6 275), is amended by striking ‘‘and 2009’’ and inserting 

7 ‘‘2009, and 2010’’. 

8 SEC. 18. MEDICARE REMOTE MONITORING PILOT 

9 PROJECTS. 

10 (a) PILOT PROJECTS.— 

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

12 after the date of enactment of this Act, the Sec13 retary of Health and Human Services (in this sec14 tion referred to as the ‘‘Secretary’’) shall conduct 

15 pilot projects under title XVIII of the Social Secu16 rity Act for the purpose of providing incentives to 

17 home health agencies to utilize home monitoring and 

18 communications technologies that— 

19 (A) enhance health outcomes for Medicare 

20 beneficiaries; and 

21 (B) reduce expenditures under such title. 

22 (2) SITE REQUIREMENTS.— 

23 (A) URBAN AND RURAL.—The Secretary 

24 shall conduct the pilot projects under this sec25 tion in both urban and rural areas. 


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1 (B) SITE IN A SMALL STATE.—The Sec2 retary shall conduct at least 3 of the pilot 

3 projects in a State with a population of less 

4 than 1,000,000. 

5 (3) DEFINITION OF HOME HEALTH AGENCY.— 

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

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

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

9 (b) MEDICARE BENEFICIARIES WITHIN THE SCOPE

10 OF PROJECTS.—The Secretary shall specify the criteria 

11 for identifying those Medicare beneficiaries who shall be 

12 considered within the scope of the pilot projects under this 

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

14 and for the assessment of the effectiveness of the home 

15 health agency in achieving the objectives of this section. 

16 Such criteria may provide for the inclusion in the projects 

17 of Medicare beneficiaries who begin receiving home health 

18 services under title XVIII of the Social Security Act after 

19 the date of the implementation of the projects. 

20 (c) INCENTIVES.— 

21 (1) PERFORMANCE TARGETS.—The Secretary 

22 shall establish for each home health agency partici23 pating in a pilot project under this section a per24 formance target using one of the following methVerDate Nov 24 2008 02:57 May 27, 2009 Jkt 079200 PO 00000 Frm 00033 Fmt 6652 Sfmt 6201 E:\BILLS\S1157.IS S1157

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1 odologies, as determined appropriate by the Sec2 retary: 

3 (A) ADJUSTED HISTORICAL PERFORMANCE

4 TARGET.—The Secretary shall establish for the 

5 agency— 

6 (i) a base expenditure amount equal 

7 to the average total payments made to the 

8 agency under parts A and B of title XVIII 

9 of the Social Security Act for Medicare 

10 beneficiaries determined to be within the 

11 scope of the pilot project in a base period 

12 determined by the Secretary; and 

13 (ii) an annual per capita expenditure 

14 target for such beneficiaries, reflecting the 

15 base expenditure amount adjusted for risk 

16 and adjusted growth rates. 

17 (B) COMPARATIVE PERFORMANCE TAR18 GET.—The Secretary shall establish for the 

19 agency a comparative performance target equal 

20 to the average total payments under such parts 

21 A and B during the pilot project for comparable 

22 individuals in the same geographic area that 

23 are not determined to be within the scope of the 

24 pilot project. 


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

2 Secretary shall pay to each participating home care 

3 agency an incentive payment for each year under the 

4 pilot project equal to a portion of the Medicare sav5 ings realized for such year relative to the perform6 ance target under paragraph (1). 

7 (3) LIMITATION ON EXPENDITURES.—The Sec8 retary shall limit incentive payments under this sec9 tion in order to ensure that the aggregate expendi10 tures under title XVIII of the Social Security Act 

11 (including incentive payments under this subsection) 

12 do not exceed the amount that the Secretary esti13 mates would have been expended if the pilot projects 

14 under this section had not been implemented. 

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

16 such provisions of titles XI and XVIII of the Social Secu17 rity Act as the Secretary determines to be appropriate for 

18 the conduct of the pilot projects under this section. 

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

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

21 is implemented, the Secretary shall submit to Congress a 

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

23 detailed description of issues related to the expansion of 

24 the projects under subsection (f) and recommendations for 


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1 such legislation and administrative actions as the Sec2 retary considers appropriate. 

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

4 any of the pilot projects under this section enhance health 

5 outcomes for Medicare beneficiaries and reduce expendi6 tures under title XVIII of the Social Security Act, the Sec7 retary may initiate comparable projects in additional 

8 areas. 

9 (g) INCENTIVE PAYMENTS HAVE NO EFFECT ON

10 OTHER MEDICARE PAYMENTS TO AGENCIES.—An incen11 tive payment under this section— 

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

13 home health agency would otherwise receive under 

14 title XVIII of the Social Security Act for the provi15 sion of home health services; and 

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

17 payments. 

18 SEC. 19. FACILITATING THE PROVISION OF TELEHEALTH 

19 SERVICES ACROSS STATE LINES. 

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

21 provision of telehealth services, for which payment is made 

22 under the Medicare program, across State lines, the Sec23 retary of Health and Human Services shall, in consulta24 tion with representatives of States, physicians, health care 

25 practitioners, and patient advocates, encourage and faciliVerDate Nov 24 2008 02:57 May 27, 2009 Jkt 079200 PO 00000 Frm 00036 Fmt 6652 Sfmt 6201 E:\BILLS\S1157.IS S1157

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1 tate the adoption of provisions allowing for multistate 

2 practitioner practice across State lines. 

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

4 (1) TELEHEALTH SERVICE.—The term ‘‘tele5 health service’’ has the meaning given that term in 

6 subparagraph (F) of section 1834(m)(4) of the So7 cial Security Act (42 U.S.C. 1395m(m)(4)). 

8 (2) PHYSICIAN, PRACTITIONER.—The terms 

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

10 given those terms in subparagraphs (D) and (E), re11 spectively, of such section. 

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

13 program’’ means the program of health insurance 

14 administered by the Secretary of Health and Human 

15 Services under title XVIII of the Social Security Act 

16 (42 U.S.C. 1395 et seq.). 

17 SEC. 20. MEDICARE PART A PAYMENT FOR ANESTHESIOL18 OGIST SERVICES IN CERTAIN RURAL HOS19 PITALS BASED ON CRNA PASS-THROUGH 

20 RULES. 

21 (a) IN GENERAL.—Section 1814 of the Social Secu22 rity Act (42 U.S.C. 1395f) is amended by adding at the 

23 end the following new subsection: 


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1 ‘‘Anesthesiologist Services Provided in Certain Rural 

2 Hospitals 

3 ‘‘(m)(1) Notwithstanding any other provision of this 

4 title, coverage and payment shall be provided under this 

5 part for physicians’ services that are anesthesia services 

6 furnished by a physician who is an anesthesiologist in a 

7 rural hospital described in paragraph (3) in the same 

8 manner as payment is made under the exception provided 

9 in section 9320(k) of the Omnibus Budget Reconciliation 

10 Act of 1986, as added by section 608(c)(2) of the Family 

11 Support Act of 1988 and amended by section 6132 of the 

12 Omnibus Budget Reconciliation Act of 1989, (relating to 

13 payment on a reasonable cost, pass-through basis) for cer14 tified registered nurse anesthetist services furnished by a 

15 certified registered nurse anesthetist in a hospital de16 scribed in such section 9320(k). 

17 ‘‘(2) No payment shall be made under any other pro18 vision of this title for physicians’ services for which pay19 ment is made under this subsection. 

20 ‘‘(3) A rural hospital described in this paragraph is 

21 a hospital described in section 9320(k) of the Omnibus 

22 Budget Reconciliation Act of 1986, as so added and 

23 amended, except that— 

24 ‘‘(A) any reference in such section to a ‘cer25 tified registered nurse anesthetist’ or an ‘anesthetist’ 


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1 is deemed a reference to a ‘physician who is an anes2 thesiologist’ or an ‘anesthesiologist’, respectively; 

3 and 

4 ‘‘(B) any reference to ‘January 1, 1988’ or 

5 ‘1987’ is deemed a reference to such date and year 

6 as the Secretary shall specify.’’. 

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

8 subsection (a) shall apply to services furnished during cost 

9 reporting periods beginning on or after the date of the 

10 enactment of this Act. 

11 SEC. 21. TEMPORARY FLOOR ON THE PRACTICE EXPENSE 

12 GEOGRAPHIC INDEX FOR SERVICES FUR13 NISHED IN RURAL AREAS UNDER THE MEDI14 CARE PHYSICIAN FEE SCHEDULE. 

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

16 U.S.C. 1395w–4(e)(1)) is amended by adding at the end 

17 the following new subparagraph: 

18 ‘‘(H) FLOOR AT 1.0 ON PRACTICE EXPENSE

19 GEOGRAPHIC INDEX FOR SERVICES FURNISHED

20 IN RURAL AREAS.—After calculating the prac21 tice expense geographic index in subparagraph 

22 (A)(i), for purposes of payment for services fur23 nished in a rural area on or after January 1, 

24 2010, and before January 1, 2012, the Sec25 retary shall increase the practice expense geoVerDate Nov 24 2008 02:57 May 27, 2009 Jkt 079200 PO 00000 Frm 00039 Fmt 6652 Sfmt 6201 E:\BILLS\S1157.IS S1157

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1 graphic index to 1.0 for any locality for which 

2 such practice expense geographic index is less 

3 than 1.0.’’. 

4 SEC. 22. TEMPORARY FLOOR ON MEDICARE HOSPITAL 

5 AREA WAGE INDEX FOR CERTAIN HOSPITALS. 

6 Section 1886(d)(3)(E) of the Social Security Act (42 

7 U.S.C. 1395ww(d)(3)(E) is amended— 

8 (1) in clause (i), by striking ‘‘clause (ii)’’ and 

9 inserting ‘‘clauses (ii) and (iii)’’; and 

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

11 clause: 

12 ‘‘(iii) TEMPORARY FLOOR FOR CERTAIN

13 HOSPITALS.—After establishing the factors 

14 under the first sentence of clause (i), for pur15 poses of payment for discharges occurring on or 

16 after January 1, 2010, and before January 1, 

17 2012, the Secretary shall increase the factor to 

18 1.0 for hospitals located in a State with less 

19 than 10 people per square mile for which such 

20 factor is less than 1.0. The Secretary shall 

21 apply the fourth sentence of clause (i) as if this 

22 clause had not been enacted.’’. 


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1 SEC. 23. REVISIONS TO STANDARD FOR DESIGNATION OF 

2 SOLE COMMUNITY HOSPITALS. 

3 Section 1886(d)(5)(D)(iv) of the Social Security Act 

4 (42 U.S.C. 1395ww(d)(5)(D)(iv)) is amended by adding 

5 at the end the following new sentence: ‘‘Under such stand6 ard, the time required for an individual to travel to the 

7 nearest alternative source of care shall be measured over 

8 improved roads maintained by a local, State, or Federal 

9 Government entity for use by the general public which is 

10 the most expeditious and accessible route as designated 

11 by law enforcement for emergency vehicle travel.’’. 

Æ 


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