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[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 1157 Introduced in Senate (IS)]

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.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Craig Thomas Rural 
Hospital and Provider Equity Act of 2009''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Fairness in the Medicare disproportionate share hospital (DSH) 
                            adjustment for rural hospitals.
Sec. 3. 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.

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

    Section 1886(d)(5)(F)(xiv)(II) of the Social Security Act (42 
U.S.C. 1395ww(d)(5)(F)(xiv)(II)) is amended--
            (1) by striking ``or, in the case'' and all that follows 
        through ``subparagraph (G)(iv)''; and
            (2) by inserting at the end the following new sentence: 
        ``The preceding sentence shall not apply to any hospital with 
        respect to discharges occurring on or after October 1, 2010.''.

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

    Section 1833(t)(7)(D)(i) of the Social Security Act (42 U.S.C. 
1395l(t)(7)(D)(i)) is amended--
            (1) in subclause (II)--
                    (A) by striking ``2010'' and inserting ``2011'';
                    (B) by striking ``and 85'' and inserting ``85''; 
                and
                    (C) in the second sentence, by inserting ``, and 
                100 percent with respect to such services furnished in 
                2010'' before the period at the end; and
            (2) in subclause (III)--
                    (A) by striking ``2010'' and inserting ``2011'';
                    (B) by striking ``85 percent'' and inserting ``the 
                applicable percentage''; and
                    (C) by adding at the end the following new 
                sentence: ``For purposes of the preceding sentence, the 
                applicable percentage shall be 85 percent with respect 
                to covered OPD services furnished in 2009 and 100 
                percent for such services furnished in 2010.''

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.

    (a) Improvement of Definition of Low-Volume Hospital for Purposes 
of the Medicare Inpatient Hospital Payment Adjustment.--Section 
1886(d)(12)(C)(i) of the Social Security Act (42 U.S.C. 
1395ww(d)(12)(C)(i)) is amended by inserting ``(or, beginning with 
fiscal year 2010, 2,000 discharges)'' after ``800 discharges''.
    (b) Temporary Improvements to the Medicare Inpatient Hospital 
Payment Adjustment for Low-Volume Hospitals.--Section 1886(d)(12) of 
the Social Security Act (42 U.S.C. 1395ww(d)(12)), as amended by 
subsection (a), is amended--
            (1) in subparagraph (A), by inserting ``or (D)'' after 
        ``subparagraph (B)'';
            (2) in subparagraph (B), by striking ``The Secretary'' and 
        inserting ``For discharges occurring in fiscal years 2005 
        through 2009 and for discharges occurring in fiscal year 2012 
        and subsequent fiscal years, the Secretary'';
            (3) in subparagraph (C)(i), by inserting ``(or, with 
        respect to fiscal years 2010 and 2011, 15 road miles)'' after 
        ``25 road miles''; and
            (4) by adding at the end the following new subparagraph:
                    ``(D) Temporary applicable percentage increase.--
                For discharges occurring in fiscal years 2010 or 2011, 
                the Secretary shall determine an applicable percentage 
                increase for purposes of subparagraph (A) using a 
                linear sliding scale ranging from 25 percent for low-
                volume hospitals with fewer than an appropriate number 
                (as determined by the Secretary) of discharges of 
                individuals entitled to, or enrolled for, benefits 
                under part A in the fiscal year to 0 percent for low-
                volume hospitals with greater than 2,000 discharges of 
                such individuals in the fiscal year.''.

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

    (a) Extension of Correction of Mid-Year Reclassification Expiration 
for Certain Hospitals.--
            (1) In general.--In the case of a hospital described in 
        paragraph (2), effective September 30, 2009, the Secretary of 
        Health and Human Services shall apply subsection (a) of section 
        106 of division B of the Tax Relief and Health Care Act of 2006 
        (42 U.S.C. 1395ww note), as amended by section 124(a) of the 
        Medicare Improvements for Patients and Providers Act of 2008 
        (Public Law 110-275) by substituting ``September 30, 2010'' for 
        ``September 30, 2009''.
            (2) Hospital described.--A hospital described in this 
        paragraph is a hospital--
                    (A) that is described in subsection (a) of such 
                section 106; and
                    (B)(i) that is located in a rural area; and
                    (ii) for which the Secretary of Health and Human 
                Services has determined the extension under this 
                subsection to be appropriate.
    (b) Additional Extension.--The Secretary of Health and Human 
Services shall extend the special exception reclassification of a sole 
community hospital located in a State with less than 10 people per 
square mile (made under the authority of section 1886(d)(5)(I)(i) of 
the Social Security Act (42 U.S.C. 1395ww(d)(5)(I)(i)) and contained in 
the final rule promulgated by the Secretary in the Federal Register on 
August 11, 2004 (69 Fed. Reg. 49107)) under section 117(a)(2) of the 
Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-
173), as amended by section 124(b) of the Medicare Improvements for 
Patients and Providers Act of 2008 (Public Law 110-275), through 
September 30, 2010.
    (c) Not Budget Neutral.--The provisions of this section shall not 
be effected in a budget-neutral manner.

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

    Section 416(b) of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (42 U.S.C. 1395l-4(b)), as amended by section 
107 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public 
Law 110-173), is amended by inserting ``, or, beginning during the 
period beginning on July 1, 2010, and ending on June 30, 2011'' after 
``2008''.

SEC. 7. ELIMINATION OF ISOLATION TEST FOR COST-BASED AMBULANCE 
              REIMBURSEMENT FOR CRITICAL ACCESS HOSPITALS.

    (a) In General.--Section 1834(l)(8) of the Social Security Act (42 
U.S.C. 1395m(l)(8)) is amended--
            (1) in subparagraph (B)--
                    (A) by striking ``owned and''; and
                    (B) by inserting ``(including when such services 
                are provided by the entity under an arrangement with 
                the hospital)'' after ``hospital''; and
            (2) by striking the comma at the end of subparagraph (B) 
        and all that follows and inserting a period.
    (b) Effective Date.--The amendments made by this section shall 
apply to services furnished on or after January 1, 2010.

SEC. 8. CAPITAL INFRASTRUCTURE REVOLVING LOAN PROGRAM.

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

            ``capital infrastructure revolving loan program

    ``Sec. 1603.  (a) Authority To Make and Guarantee Loans.--
            ``(1) Authority to make loans.--The Secretary may make 
        loans from the fund established under section 1602(d) to any 
        rural entity for projects for capital improvements, including--
                    ``(A) the acquisition of land necessary for the 
                capital improvements;
                    ``(B) the renovation or modernization of any 
                building;
                    ``(C) the acquisition or repair of fixed or major 
                movable equipment; and
                    ``(D) such other project expenses as the Secretary 
                determines appropriate.
            ``(2) Authority to guarantee loans.--
                    ``(A) In general.--The Secretary may guarantee the 
                payment of principal and interest for loans made to 
                rural entities for projects for any capital improvement 
                described in paragraph (1) to any non-Federal lender.
                    ``(B) Interest subsidies.--In the case of a 
                guarantee of any loan made to a rural entity under 
                subparagraph (A), the Secretary may pay to the holder 
                of such loan, for and on behalf of the project for 
                which the loan was made, amounts sufficient to reduce 
                (by not more than 3 percent) the net effective interest 
                rate otherwise payable on such loan.
    ``(b) Amount of Loan.--The principal amount of a loan directly made 
or guaranteed under subsection (a) for a project for capital 
improvement may not exceed $5,000,000.
    ``(c) Funding Limitations.--
            ``(1) Government credit subsidy exposure.--The total of the 
        Government credit subsidy exposure under the Credit Reform Act 
        of 1990 scoring protocol with respect to the loans outstanding 
        at any time with respect to which guarantees have been issued, 
        or which have been directly made, under subsection (a) may not 
        exceed $50,000,000 per year.
            ``(2) Total amounts.--Subject to paragraph (1), the total 
        of the principal amount of all loans directly made or 
        guaranteed under subsection (a) may not exceed $250,000,000 per 
        year.
    ``(d) Capital Assessment and Planning Grants.--
            ``(1) Nonrepayable grants.--Subject to paragraph (2), the 
        Secretary may make a grant to a rural entity, in an amount not 
        to exceed $50,000, for purposes of capital assessment and 
        business planning.
            ``(2) Limitation.--The cumulative total of grants awarded 
        under this subsection may not exceed $2,500,000 per year.
    ``(e) Termination of Authority.--The Secretary may not directly 
make or guarantee any loan under subsection (a) or make a grant under 
subsection (d) after September 30, 2013.''.
    (b) Rural Entity Defined.--Section 1624 of the Public Health 
Service Act (42 U.S.C. 300s-3) is amended by adding at the end the 
following new paragraph:
            ``(15)(A) The term `rural entity' includes--
                    ``(i) a rural health clinic, as defined in section 
                1861(aa)(2) of the Social Security Act;
                    ``(ii) any medical facility with at least 1 bed, 
                but with less than 50 beds, that is located in--
                            ``(I) a county that is not part of a 
                        metropolitan statistical area; or
                            ``(II) a rural census tract of a 
                        metropolitan statistical area (as determined 
                        under the most recent modification of the 
                        Goldsmith Modification, originally published in 
                        the Federal Register on February 27, 1992 (57 
                        Fed. Reg. 6725));
                    ``(iii) a hospital that is classified as a rural, 
                regional, or national referral center under section 
                1886(d)(5)(C) of the Social Security Act; and
                    ``(iv) a hospital that is a sole community hospital 
                (as defined in section 1886(d)(5)(D)(iii) of the Social 
                Security Act).
            ``(B) For purposes of subparagraph (A), the fact that a 
        clinic, facility, or hospital has been geographically 
        reclassified under the Medicare program under title XVIII of 
        the Social Security Act shall not preclude a hospital from 
        being considered a rural entity under clause (i) or (ii) of 
        subparagraph (A).''.
    (c) Conforming Amendments.--Section 1602 of the Public Health 
Service Act (42 U.S.C. 300q-2) is amended--
            (1) in subsection (b)(2)(D), by inserting ``or 
        1603(a)(2)(B)'' after ``1601(a)(2)(B)''; and
            (2) in subsection (d)--
                    (A) in paragraph (1)(C), by striking ``section 
                1601(a)(2)(B)'' and inserting ``sections 1601(a)(2)(B) 
                and 1603(a)(2)(B)''; and
                    (B) in paragraph (2)(A), by inserting ``or 
                1603(a)(2)(B)'' after ``1601(a)(2)(B)''.

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

    Section 1833(u)(1) of the Social Security Act (42 U.S.C. 
1395l(u)(1)) is amended by inserting ``, and such services furnished on 
or after January 1, 2010, and before July 1, 2011'' after ``2008''.

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

    Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w-
4(e)(1)(E)) is amended by striking ``before January 1, 2010'' and 
inserting ``before January 1, 2011''.

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.

    (a) Permitting Physician Assistants To Order Post-Hospital Extended 
Care Services and To Provide for Recognition of Attending Physician 
Assistants as Attending Physicians To Serve Hospice Patients.--
            (1) Ordering post-hospital extended care services.--
                    (A) In general.--Section 1814(a)(2) of the Social 
                Security Act (42 U.S.C. 1395f(a)(2)), in the matter 
                preceding subparagraph (A), is amended by striking 
                ``nurse practitioner or clinical nurse specialist'' and 
                inserting ``nurse practitioner, a clinical nurse 
                specialist, or a physician assistant (as those terms 
                are defined in section 1861(aa)(5))''.
                    (B) Conforming amendment.--Section 1814(a) of the 
                Social Security Act (42 U.S.C. 1395f(a)) is amended, in 
                the second sentence, by striking ``or clinical nurse 
                specialist'' and inserting ``clinical nurse specialist, 
                or physician assistant''.
            (2) Recognition of attending physician assistants as 
        attending physicians to serve hospice patients.--
                    (A) In general.--Section 1861(dd)(3)(B) of the 
                Social Security Act (42 U.S.C. 1395x(dd)(3)(B)) is 
                amended--
                            (i) by striking ``or nurse'' and inserting 
                        ``, the nurse''; and
                            (ii) by inserting ``, or the physician 
                        assistant (as defined in such subsection)'' 
                        after ``subsection (aa)(5))''.
                    (B) Permitting physician assistants when delegated 
                by a physician to order hospice care.--Section 
                1814(a)(7)(A) of such Act (42 U.S.C. 1395f(a)(7)(A)) is 
                amended--
                            (i) in clause (i)(I), by inserting ``or a 
                        physician assistant as delegated by such 
                        attending physician'' after ``nurse 
                        practitioner)''; and
                            (ii) in clause (ii), by inserting ``or 
                        physician assistant'' after ``physician''.
    (b) Improving Care Planning for Medicare Home Health Services.--
            (1) In general.--Section 1814(a)(2) of the Social Security 
        Act (42 U.S.C. 1395f(a)(2)), in the matter preceding 
        subparagraph (A), is amended by inserting ``, or in the case of 
        services described in subparagraph (C), a physician, or a nurse 
        practitioner or clinical nurse specialist who is working in 
        collaboration with a physician in accordance with State law, or 
        a certified nurse-midwife (as defined in section 1861(gg)) as 
        authorized by State law, or a physician assistant (as defined 
        in section 1861(aa)(5)) under the supervision of a physician'' 
        after ``collaboration with a physician''.
            (2) Conforming amendments.--(A) Section 1814(a) of the 
        Social Security Act (42 U.S.C. 1395f(a)), as amended by 
        subsection (a), is amended--
                    (i) in paragraph (2)(C), by inserting ``, a nurse 
                practitioner, a clinical nurse specialist, a certified 
                nurse-midwife, or a physician assistant (as the case 
                may be)'' after ``physician'' each place it appears;
                    (ii) in the second sentence, by striking ``clinical 
                nurse specialist, or physician assistant'' and 
                inserting ``clinical nurse specialist, certified nurse-
                midwife, or physician assistant'';
                    (iii) in the third sentence--
                            (I) by striking ``physician certification'' 
                        and inserting ``certification'';
                            (II) by inserting ``(or on January 1, 2010, 
                        in the case of regulations to implement the 
                        amendments made by section 11 of the Craig 
                        Thomas Rural Hospital and Provider Equity Act 
                        of 2009)'' after ``1981''; and
                            (III) by striking ``a physician who'' and 
                        inserting ``a physician, nurse practitioner, 
                        clinical nurse specialist, certified nurse-
                        midwife, or physician assistant who''; and
                    (iv) in the fourth sentence, by inserting ``, nurse 
                practitioner, clinical nurse specialist, certified 
                nurse-midwife, or physician assistant'' after 
                ``physician''.
            (B) Section 1835(a) of the Social Security Act (42 U.S.C. 
        1395n(a)) is amended--
                    (i) in paragraph (2)--
                            (I) in the matter preceding subparagraph 
                        (A), by inserting ``or, in the case of services 
                        described in subparagraph (A), a physician, or 
                        a nurse practitioner or clinical nurse 
                        specialist (as those terms are defined in 
                        1861(aa)(5)) who is working in collaboration 
                        with a physician in accordance with State law, 
                        or a certified nurse-midwife (as defined in 
                        section 1861(gg)) as authorized by State law, 
                        or a physician assistant (as defined in section 
                        1861(aa)(5)) under the supervision of a 
                        physician'' after ``a physician''; and
                            (II) in each of clauses (ii) and (iii) of 
                        subparagraph (A) by inserting ``, a nurse 
                        practitioner, a clinical nurse specialist, a 
                        certified nurse-midwife, or a physician 
                        assistant (as the case may be)'' after 
                        ``physician'';
                    (ii) in the third sentence, by inserting ``, nurse 
                practitioner, clinical nurse specialist, certified 
                nurse-midwife, or physician assistant (as the case may 
                be)'' after physician;
                    (iii) in the fourth sentence--
                            (I) by striking ``physician certification'' 
                        and inserting ``certification'';
                            (II) by inserting ``(or on January 1, 2010, 
                        in the case of regulations to implement the 
                        amendments made by section 11 of the Craig 
                        Thomas Rural Hospital and Provider Equity Act 
                        of 2009)'' after ``1981''; and
                            (III) by striking ``a physician who'' and 
                        inserting ``a physician, nurse practitioner, 
                        clinical nurse specialist, certified nurse-
                        midwife, or physician assistant who''; and
                    (iv) in the fifth sentence, by inserting ``, nurse 
                practitioner, clinical nurse specialist, certified 
                nurse-midwife, or physician assistant'' after 
                ``physician''.
            (C) Section 1861 of the Social Security Act (42 U.S.C. 
        1395x) is amended--
                    (i) in subsection (m)--
                            (I) in the matter preceding paragraph (1)--
                                    (aa) by inserting ``a nurse 
                                practitioner or a clinical nurse 
                                specialist (as those terms are defined 
                                in subsection (aa)(5)), a certified 
                                nurse-midwife (as defined in section 
                                1861(gg)), or a physician assistant (as 
                                defined in subsection (aa)(5))'' after 
                                ``physician'' the first place it 
                                appears; and
                                    (bb) by inserting ``a nurse 
                                practitioner, a clinical nurse 
                                specialist, a certified nurse-midwife, 
                                or a physician assistant'' after 
                                ``physician'' the second place it 
                                appears; and
                            (II) in paragraph (3), by inserting ``a 
                        nurse practitioner, a clinical nurse 
                        specialist, a certified nurse-midwife, or a 
                        physician assistant'' after ``physician''; and
                    (ii) in subsection (o)(2)--
                            (I) by inserting ``, nurse practitioners or 
                        clinical nurse specialists (as those terms are 
                        defined in subsection (aa)(5)), certified 
                        nurse-midwives (as defined in section 
                        1861(gg)), or physician assistants (as defined 
                        in subsection (aa)(5))'' after ``physicians''; 
                        and
                            (II) by inserting ``, nurse practitioner, 
                        clinical nurse specialist, certified nurse-
                        midwife, physician assistant,'' after 
                        ``physician''.
            (D) Section 1895 of the Social Security Act (42 U.S.C. 
        1395fff) is amended--
                    (i) in subsection (c)(1), by inserting ``, the 
                nurse practitioner or clinical nurse specialist (as 
                those terms are defined in section 1861(aa)(5)), the 
                certified nurse-midwife (as defined in section 
                1861(gg)), or the physician assistant (as defined in 
                section 1861(aa)(5)),'' after ``physician''; and
                    (ii) in subsection (e)--
                            (I) in paragraph (1)(A), by inserting ``, a 
                        nurse practitioner or clinical nurse specialist 
                        (as those terms are defined in section 
                        1861(aa)(5)), a certified nurse-midwife (as 
                        defined in section 1861(gg)), or a physician 
                        assistant (as defined in section 1861(aa)(5))'' 
                        after ``physician''; and
                            (II) in paragraph (2)--
                                    (aa) in the heading, by striking 
                                ``Physician certification'' and 
                                inserting ``Rule of construction 
                                regarding requirement for 
                                certification''; and
                                    (bb) by striking ``physician''.
    (c) Effective Date.--The amendments made by this section shall 
apply to items and services furnished on or after January 1, 2010.

SEC. 12. RURAL HEALTH CLINIC IMPROVEMENTS.

    Section 1833(f) of the Social Security Act (42 U.S.C. 1395l(f)) is 
amended--
            (1) in paragraph (1), by striking ``, and'' at the end and 
        inserting a semicolon;
            (2) in paragraph (2)--
                    (A) by inserting ``(before 2010)'' after ``in a 
                subsequent year''; and
                    (B) by striking the period at the end and inserting 
                a semicolon; and
            (3) by adding at the end the following new paragraphs:
            ``(3) in 2010, at $92 per visit; and
            ``(4) in a subsequent year, at the limit established under 
        this subsection for the previous year increased by the 
        percentage increase in the MEI (as so defined) applicable to 
        primary care services (as so defined) furnished as of the first 
        day of that year.''.

SEC. 13. COMMUNITY HEALTH CENTER COLLABORATIVE ACCESS EXPANSION.

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

SEC. 14. APPLICATION OF THE TEMPORARY MEDICARE PAYMENT INCREASE FOR 
              HOME HEALTH SERVICES FURNISHED IN A RURAL AREA TO 2010.

    Section 421 of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (42 U.S.C. 1395fff note), as amended by 
section 5201(b) of the Deficit Reduction Act of 2005 (42 U.S.C. 1395fff 
note), is amended--
            (1) in the section heading, by striking ``one-year'' and 
        inserting ``temporary''; and
            (2) in subsection (a), by inserting ``and episodes and 
        visits ending on or after January 1, 2010, and before January 
        1, 2011,'' after ``January 1, 2007,''.

SEC. 15. EXTENSION OF INCREASED MEDICARE PAYMENTS FOR RURAL GROUND 
              AMBULANCE SERVICES.

    Section 1834(l)(13) of the Social Security Act (42 U.S.C. 
1395m(l)(13)) is amended--
            (1) in subparagraph (A), in the heading, by striking ``In 
        general'' and inserting ``For the second half of 2004 and for 
        2005, 2006, the second half of 2008, and 2009'';
            (2) by redesignating subparagraph (B) as subparagraph (C);
            (3) by inserting the following after subparagraph (A):
                    ``(B) For 2010 and 2011 for rural areas.--After 
                computing the rates with respect to ground ambulance 
                services under the other applicable provisions of this 
                subsection, in the case of such services furnished on 
                or after January 1, 2010, and before January 1, 2012, 
                for which the transportation originates in a rural area 
                described in paragraph (9) or in a rural census tract 
                described in such paragraph, the fee schedule 
                established under this section shall provide that the 
                rate for the service otherwise established, after 
                application of any increase under paragraphs (11) and 
                (12), shall be increased by 5 percent.''; and
            (4) in subparagraph (C), as redesignated by paragraph (2)--
                    (A) in the heading, by striking ``Application of 
                increased payments after applicable period'' and 
                inserting ``No effect on subsequent periods''; and
                    (B) by adding at the end the following new 
                sentence: ``The increased payments under subparagraph 
                (B) shall not be taken into account in calculating 
                payments for services furnished after the period 
                specified in such subparagraph.''.

SEC. 16. COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES AND MENTAL 
              HEALTH COUNSELOR SERVICES UNDER PART B OF THE MEDICARE 
              PROGRAM.

    (a) Coverage of Services.--
            (1) In general.--Section 1861(s)(2) of the Social Security 
        Act (42 U.S.C. 1395x(s)(2)) is amended--
                    (A) in subparagraph (DD), by striking ``and'' after 
                the semicolon at the end;
                    (B) in subparagraph (EE), by inserting ``and'' 
                after the semicolon at the end; and
                    (C) by adding at the end the following new 
                subparagraph:
            ``(FF) marriage and family therapist services (as defined 
        in subsection (hhh)(1)) and mental health counselor services 
        (as defined in subsection (hhh)(3));''.
            (2) Definitions.--Section 1861 of the Social Security Act 
        (42 U.S.C. 1395x) is amended by adding at the end the following 
        new subsection:

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

    ``(hhh)(1) The term `marriage and family therapist services' means 
services performed by a marriage and family therapist (as defined in 
paragraph (2)) for the diagnosis and treatment of mental illnesses, 
which the marriage and family therapist is legally authorized to 
perform under State law (or the State regulatory mechanism provided by 
State law) of the State in which such services are performed, as would 
otherwise be covered if furnished by a physician or as an incident to a 
physician's professional service, but only if no facility or other 
provider charges or is paid any amounts with respect to the furnishing 
of such services.
    ``(2) The term `marriage and family therapist' means an individual 
who--
            ``(A) possesses a master's or doctoral degree which 
        qualifies for licensure or certification as a marriage and 
        family therapist pursuant to State law;
            ``(B) after obtaining such degree has performed at least 2 
        years of clinical supervised experience in marriage and family 
        therapy; and
            ``(C) in the case of an individual performing services in a 
        State that provides for licensure or certification of marriage 
        and family therapists, is licensed or certified as a marriage 
        and family therapist in such State.
    ``(3) The term `mental health counselor services' means services 
performed by a mental health counselor (as defined in paragraph (4)) 
for the diagnosis and treatment of mental illnesses which the mental 
health counselor is legally authorized to perform under State law (or 
the State regulatory mechanism provided by the State law) of the State 
in which such services are performed, as would otherwise be covered if 
furnished by a physician or as incident to a physician's professional 
service, but only if no facility or other provider charges or is paid 
any amounts with respect to the furnishing of such services.
    ``(4) The term `mental health counselor' means an individual who--
            ``(A) possesses a master's or doctor's degree in mental 
        health counseling or a related field;
            ``(B) after obtaining such a degree has performed at least 
        2 years of supervised mental health counselor practice; and
            ``(C) in the case of an individual performing services in a 
        State that provides for licensure or certification of mental 
        health counselors or professional counselors, is licensed or 
        certified as a mental health counselor or professional 
        counselor in such State.''.
            (3) Provision for payment under part b.--Section 
        1832(a)(2)(B) of the Social Security Act (42 U.S.C. 
        1395k(a)(2)(B)) is amended by adding at the end the following 
        new clause:
                            ``(v) marriage and family therapist 
                        services (as defined in section 1861(hhh)(1)) 
                        and mental health counselor services (as 
                        defined in section 1861(hhh)(3));''.
            (4) Amount of payment.--Section 1833(a)(1) of the Social 
        Security Act (42 U.S.C. 1395l(a)(1)) is amended--
                    (A) by striking ``and (W)'' and inserting ``(W)''; 
                and
                    (B) by inserting before the semicolon at the end 
                the following: ``, and (X) with respect to marriage and 
                family therapist services and mental health counselor 
                services under section 1861(s)(2)(BB), the amounts paid 
                shall be 80 percent of the lesser of the actual charge 
                for the services or 75 percent of the amount determined 
                for payment of a psychologist under subparagraph (L)''.
            (5) Exclusion of marriage and family therapist services and 
        mental health counselor services from skilled nursing facility 
        prospective payment system.--Section 1888(e)(2)(A)(ii) of the 
        Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended 
        by inserting ``marriage and family therapist services (as 
        defined in section 1861(hhh)(1)), mental health counselor 
        services (as defined in section 1861(hhh)(3)),'' after 
        ``qualified psychologist services,''.
            (6) Inclusion of marriage and family therapists and mental 
        health counselors as practitioners for assignment of claims.--
        Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 
        1395u(b)(18)(C)) is amended by adding at the end the following 
        new clauses:
            ``(vii) A marriage and family therapist (as defined in 
        section 1861(hhh)(2)).
            ``(viii) A mental health counselor (as defined in section 
        1861(hhh)(4)).''.
    (b) Coverage of Certain Mental Health Services Provided in Certain 
Settings.--
            (1) Rural health clinics and federally qualified health 
        centers.--Section 1861(aa)(1)(B) of the Social Security Act (42 
        U.S.C. 1395x(aa)(1)(B)) is amended by striking ``or by a 
        clinical social worker (as defined in subsection (hh)(1))'' and 
        inserting ``, by a clinical social worker (as defined in 
        subsection (hh)(1)), by a marriage and family therapist (as 
        defined in subsection (hhh)(2)), or by a mental health 
        counselor (as defined in subsection (hhh)(4))''.
            (2) Hospice programs.--Section 1861(dd)(2)(B)(i)(III) of 
        the Social Security Act (42 U.S.C. 1395x(dd)(2)(B)(i)(III)) is 
        amended by inserting ``, marriage and family therapist, or 
        mental health counselor'' after ``social worker''.
    (c) Authorization of Marriage and Family Therapists and Mental 
Health Counselors To Develop Discharge Plans for Post-Hospital 
Services.--Section 1861(ee)(2)(G) of the Social Security Act (42 U.S.C. 
1395x(ee)(2)(G)) is amended by inserting ``, including a marriage and 
family therapist and a mental health counselor who meets qualification 
standards established by the Secretary'' before the period at the end.
    (d) Effective Date.--The amendments made by this section shall 
apply with respect to services furnished on or after January 1, 2010.

SEC. 17. EXTENSION OF TREATMENT OF CERTAIN PHYSICIAN PATHOLOGY SERVICES 
              UNDER MEDICARE.

    Section 542(c) of the Medicare, Medicaid, and SCHIP Benefits 
Improvement and Protection Act of 2000 (as enacted into law by section 
1(a)(6) of Public Law 106-554), as amended by section 732 of the 
Medicare Prescription Drug, Improvement, and Modernization Act of 2003 
(42 U.S.C. 1395w-4 note), section 104 of division B of the Tax Relief 
and Health Care Act of 2006 (42 U.S.C. 1395w-4 note), section 104 of 
the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 
110-173), and section 136 of the Medicare Improvements for Patients and 
Providers Act of 2008 (Public Law 110-275), is amended by striking 
``and 2009'' and inserting ``2009, and 2010''.

SEC. 18. MEDICARE REMOTE MONITORING PILOT PROJECTS.

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

SEC. 19. FACILITATING THE PROVISION OF TELEHEALTH SERVICES ACROSS STATE 
              LINES.

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

SEC. 20. MEDICARE PART A PAYMENT FOR ANESTHESIOLOGIST SERVICES IN 
              CERTAIN RURAL HOSPITALS BASED ON CRNA PASS-THROUGH RULES.

    (a) In General.--Section 1814 of the Social Security Act (42 U.S.C. 
1395f) is amended by adding at the end the following new subsection:

    ``Anesthesiologist Services Provided in Certain Rural Hospitals

    ``(m)(1) Notwithstanding any other provision of this title, 
coverage and payment shall be provided under this part for physicians' 
services that are anesthesia services furnished by a physician who is 
an anesthesiologist in a rural hospital described in paragraph (3) in 
the same manner as payment is made under the exception provided in 
section 9320(k) of the Omnibus Budget Reconciliation Act of 1986, as 
added by section 608(c)(2) of the Family Support Act of 1988 and 
amended by section 6132 of the Omnibus Budget Reconciliation Act of 
1989, (relating to payment on a reasonable cost, pass-through basis) 
for certified registered nurse anesthetist services furnished by a 
certified registered nurse anesthetist in a hospital described in such 
section 9320(k).
    ``(2) No payment shall be made under any other provision of this 
title for physicians' services for which payment is made under this 
subsection.
    ``(3) A rural hospital described in this paragraph is a hospital 
described in section 9320(k) of the Omnibus Budget Reconciliation Act 
of 1986, as so added and amended, except that--
            ``(A) any reference in such section to a `certified 
        registered nurse anesthetist' or an `anesthetist' is deemed a 
        reference to a `physician who is an anesthesiologist' or an 
        `anesthesiologist', respectively; and
            ``(B) any reference to `January 1, 1988' or `1987' is 
        deemed a reference to such date and year as the Secretary shall 
        specify.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to services furnished during cost reporting periods beginning on 
or after the date of the enactment of this Act.

SEC. 21. TEMPORARY FLOOR ON THE PRACTICE EXPENSE GEOGRAPHIC INDEX FOR 
              SERVICES FURNISHED IN RURAL AREAS UNDER THE MEDICARE 
              PHYSICIAN FEE SCHEDULE.

    Section 1848(e)(1) of the Social Security Act (42 U.S.C. 1395w-
4(e)(1)) is amended by adding at the end the following new 
subparagraph:
                    ``(H) Floor at 1.0 on practice expense geographic 
                index for services furnished in rural areas.--After 
                calculating the practice expense geographic index in 
                subparagraph (A)(i), for purposes of payment for 
                services furnished in a rural area on or after January 
                1, 2010, and before January 1, 2012, the Secretary 
                shall increase the practice expense geographic index to 
                1.0 for any locality for which such practice expense 
                geographic index is less than 1.0.''.

SEC. 22. TEMPORARY FLOOR ON MEDICARE HOSPITAL AREA WAGE INDEX FOR 
              CERTAIN HOSPITALS.

    Section 1886(d)(3)(E) of the Social Security Act (42 U.S.C. 
1395ww(d)(3)(E) is amended--
            (1) in clause (i), by striking ``clause (ii)'' and 
        inserting ``clauses (ii) and (iii)''; and
            (2) by adding at the end the following new clause:
                    ``(iii) Temporary floor for certain hospitals.--
                After establishing the factors under the first sentence 
                of clause (i), for purposes of payment for discharges 
                occurring on or after January 1, 2010, and before 
                January 1, 2012, the Secretary shall increase the 
                factor to 1.0 for hospitals located in a State with 
                less than 10 people per square mile for which such 
                factor is less than 1.0. The Secretary shall apply the 
                fourth sentence of clause (i) as if this clause had not 
                been enacted.''.

SEC. 23. REVISIONS TO STANDARD FOR DESIGNATION OF SOLE COMMUNITY 
              HOSPITALS.

    Section 1886(d)(5)(D)(iv) of the Social Security Act (42 U.S.C. 
1395ww(d)(5)(D)(iv)) is amended by adding at the end the following new 
sentence: ``Under such standard, the time required for an individual to 
travel to the nearest alternative source of care shall be measured over 
improved roads maintained by a local, State, or Federal Government 
entity for use by the general public which is the most expeditious and 
accessible route as designated by law enforcement for emergency vehicle 
travel.''.
                                 <all>
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