II 

113TH CONGRESS 

2D SESSION S. 2359 

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 20, 2014 

Mr. FRANKEN (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 2014’’. 

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. Sense of the Senate. 

Sec. 3. Fairness in the Medicare disproportionate share hospital (DSH) adjustment for rural hospitals. 

Sec. 4. Extension and expansion of the Medicare hold harmless provision under 

the prospective payment system for hospital outpatient department (HOPD) services for certain hospitals. 

Sec. 5. Temporary improvements to the Medicare inpatient hospital payment 

adjustment for low-volume hospitals. 

Sec. 6. Extension of Medicare wage index reclassifications for certain hospitals. 

Sec. 7. Extension of Medicare reasonable costs payments for certain clinical diagnostic laboratory tests furnished to hospital patients in certain rural areas. 

Sec. 8. Elimination of isolation test for cost-based ambulance reimbursement 

for critical access hospitals. 

Sec. 9. Capital infrastructure revolving loan program. 

Sec. 10. Extension of Medicare incentive payment program for physician scarcity areas. 

Sec. 11. Extension of floor on Medicare work geographic adjustment. 

Sec. 12. Recognition of attending physician assistants as attending physicians 

to serve hospice patients. 

Sec. 13. Improving care planning for Medicare home health services. 

Sec. 14. Rural health clinic improvements. 

Sec. 15. Temporary Medicare payment increase for home health services furnished in a rural area. 

Sec. 16. Extension of increased Medicare payments for rural ground ambulance 

services. 

Sec. 17. Coverage of marriage and family therapist services and mental health 

counselor services under Part B of the Medicare program. 

Sec. 18. Extension of payment for technical component of certain physician pathology services. 

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 outside of frontier States under the 

Medicare physician fee schedule. 

Sec. 22. Revisions to standard for designation of sole community hospitals. 

Sec. 23. Medicare treatment of standby and on-call time for CRNA services. 

Sec. 24. State offices of rural health. 

Sec. 25. Removing Medicare 96-hour physician certification requirement for inpatient critical access hospital services. 

Sec. 26. Extension of enforcement instruction on supervision requirements for 

outpatient therapeutic services in critical access and small 

rural hospitals through 2014. 

1 SEC. 2. SENSE OF THE SENATE. 

2 It is the sense of the Senate that— 

3 (1) residents of rural and frontier communities 

4 should have access to affordable, quality health care; 


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1 (2) rural and frontier communities face unique 

2 challenges in health care delivery and financing; 

3 (3) Federal health policy must reflect the 

4 unique needs of residents of rural and frontier com5 munities and such communities in an equitable and 

6 sustainable manner; and 

7 (4) stakeholders should work collectively to 

8 identify innovative policies that address the avail9 ability, delivery, and affordability of health care 

10 services in rural and frontier communities. 

11 SEC. 3. FAIRNESS IN THE MEDICARE DISPROPORTIONATE 

12 SHARE HOSPITAL (DSH) ADJUSTMENT FOR 

13 RURAL HOSPITALS. 

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

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

16 adding at the end the following new sentence: ‘‘The pre17 ceding sentence shall not apply to any hospital with re18 spect to discharges occurring on or after October 1, 2014, 

19 and before October 1, 2015.’’. 


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1 SEC. 4. EXTENSION AND EXPANSION OF THE MEDICARE 

2 HOLD HARMLESS PROVISION UNDER THE 

3 PROSPECTIVE PAYMENT SYSTEM FOR HOS4 PITAL OUTPATIENT DEPARTMENT (HOPD) 

5 SERVICES FOR CERTAIN HOSPITALS. 

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

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

8 (1) in subclause (II)— 

9 (A) in the first sentence, by inserting ‘‘and 

10 for such services furnished on or after April 1, 

11 2014, and before April 1, 2015,’’ after ‘‘covered 

12 OPD services furnished on or after January 1, 

13 2006, and before January 1, 2013,’’; and 

14 (B) in the second sentence— 

15 (i) by striking ‘‘and 85’’ and inserting 

16 ‘‘85’’; and 

17 (ii) by inserting the following before 

18 the period at the end: ‘‘, and 100 percent 

19 with respect to such services furnished 

20 after April 1, 2014, and before April 1, 

21 2015’’; and 

22 (2) in subclause (III)— 

23 (A) in the first sentence— 

24 (i) by inserting ‘‘and for such services 

25 furnished on or after April 1, 2014, and 

26 before April 1, 2015,’’ after ‘‘covered OPD 


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1 services furnished on or after January 1, 

2 2009, and before January 1, 2013,’’; and 

3 (ii) by striking ‘‘85 percent’’ and in4 serting ‘‘the applicable percentage (as de5 termined under the second sentence of sub6 clause (II) for the year)’’; and 

7 (B) in the second sentence, by inserting 

8 ‘‘and in the case of such services furnished on 

9 or after April 1, 2014, and before April 1, 

10 2015,’’ after ‘‘covered OPD services furnished 

11 on or after January 1, 2010, and before March 

12 1, 2012,’’. 

13 SEC. 5. TEMPORARY IMPROVEMENTS TO THE MEDICARE 

14 INPATIENT HOSPITAL PAYMENT ADJUST15 MENT FOR LOW-VOLUME HOSPITALS. 

16 Section 1886(d)(12) of the Social Security Act (42 

17 U.S.C. 1395ww(d)(12)) is amended— 

18 (1) in subparagraph (C)(i), by striking ‘‘fiscal 

19 years 2011 through 2014 and fiscal year 2015 (be20 fore April 1, 2015), 1,600 discharges of individuals 

21 entitled to, or enrolled for, benefits under part A’’ 

22 and inserting ‘‘fiscal years 2011 through 2013 and 

23 fiscal year 2014 (before April 1, 2014), 1,600 dis24 charges of individuals entitled to, or enrolled for, 

25 benefits under part A, or, with respect to fiscal year 


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1 2014 (after April 1, 2014), fiscal year 2015, and fis2 cal year 2016 (before January 1, 2016), 2,000 dis3 charges of such individuals’’; and 

4 (2) in subparagraph (D)— 

5 (A) by striking ‘‘1,600’’ and inserting ‘‘the 

6 applicable number of’’; and 

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

8 sentence: ‘‘For purposes of the preceding sen9 tence, the term ‘applicable number of dis10 charges’ means 1,600 discharges with respect to 

11 discharges occurring in fiscal years 2011, 2012, 

12 and 2013, and fiscal year 2014 (before April 1, 

13 2014), and 2,000 discharges with respect to 

14 discharges occurring in fiscal year 2014 (after 

15 April 1, 2014), fiscal year 2015, and fiscal year 

16 2016 (before January 1, 2016).’’. 

17 SEC. 6. EXTENSION OF MEDICARE WAGE INDEX RECLASSI18 FICATIONS FOR CERTAIN HOSPITALS. 

19 (a) EXTENSION OF CORRECTION OF MID-YEAR RE20 CLASSIFICATION EXPIRATION FOR CERTAIN HOS21 PITALS.— 

22 (1) IN GENERAL.—In the case of a hospital de23 scribed in paragraph (2), the Secretary of Health 

24 and Human Services shall apply subsection (a) of 

25 section 106 of division B of the Tax Relief and 


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1 Health Care Act of 2006 (42 U.S.C. 1395ww note), 

2 as amended by section 117 of the Medicare, Med3 icaid, and SCHIP Extension Act of 2007 (Public 

4 Law 110–173), section 124 of the Medicare Im5 provements for Patients and Providers Act of 2008 

6 (Public Law 110–275), sections 3137(a) and 10317 

7 of the Patient Protection and Affordable Care Act 

8 (Public Law 111–148), and section 102 of the Medi9 care and Medicaid Extenders Act of 2010 (Public 

10 Law 111–309), by substituting ‘‘April 1, 2015’’ for 

11 ‘‘March 31, 2012’’. 

12 (2) HOSPITAL DESCRIBED.—A hospital de13 scribed in this paragraph is— 

14 (A) a hospital— 

15 (i) that is described in subsection (a) 

16 of such section 106; and 

17 (ii)(I) that is located in a rural area; 

18 and 

19 (II) for which the Secretary of Health 

20 and Human Services has determined the 

21 extension under this subsection to be ap22 propriate; or 

23 (B) a sole community hospital located in a 

24 State with less than 10 people per square mile 

25 that was provided with a special exception reVerDate Mar 15 2010 01:08 May 23, 2014 Jkt 039200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S2359.IS S2359

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1 classification extension under section 117(a)(2) 

2 of the Medicare, Medicaid, and SCHIP Exten3 sion Act of 2007 (Public Law 110–173). 

4 (b) NOT BUDGET NEUTRAL.—The provisions of this 

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

6 SEC. 7. EXTENSION OF MEDICARE REASONABLE COSTS 

7 PAYMENTS FOR CERTAIN CLINICAL DIAG8 NOSTIC LABORATORY TESTS FURNISHED TO 

9 HOSPITAL PATIENTS IN CERTAIN RURAL 

10 AREAS. 

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

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

13 1395l–4), as amended by section 105 of division B of the 

14 Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395l 

15 note), section 107 of the Medicare, Medicaid, and SCHIP 

16 Extension Act of 2007 (42 U.S.C. 1395l note), section 

17 3122 of the Patient Protection and Affordable Care Act 

18 (Public Law 111–148), and section 109 of the Medicare 

19 and Medicaid Extenders Act of 2010 (Public Law 111– 

20 309), is amended by inserting ‘‘, the portion of fiscal year 

21 2014 after April 1, 2014, or the portion of fiscal year 

22 2015 before April 1, 2015’’ after ‘‘the 2-year period begin23 ning on July 1, 2010’’. 


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1 SEC. 8. ELIMINATION OF ISOLATION TEST FOR COST-BASED 

2 AMBULANCE REIMBURSEMENT FOR CRIT3 ICAL ACCESS HOSPITALS. 

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

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

6 (1) in subparagraph (B)— 

7 (A) by striking ‘‘owned and’’; and 

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

9 services are provided by the entity under an ar10 rangement with the hospital)’’ after ‘‘hospital’’; 

11 and 

12 (2) by striking the comma at the end of sub13 paragraph (B) and all that follows and inserting a 

14 period. 

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

16 this section shall apply to services furnished on or after 

17 January 1, 2015. 

18 SEC. 9. CAPITAL INFRASTRUCTURE REVOLVING LOAN PRO19 GRAM. 

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

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

22 by adding at the end the following new section: 

23 ‘‘CAPITAL INFRASTRUCTURE REVOLVING LOAN PROGRAM

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


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

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

4 projects for capital improvements, including— 

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

6 the capital improvements; 

7 ‘‘(B) the renovation or modernization of 

8 any building; 

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

10 major movable equipment; and 

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

12 Secretary determines appropriate. 

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

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

15 guarantee the payment of principal and interest 

16 for loans made to rural entities for projects for 

17 any capital improvement described in paragraph 

18 (1) to any non-Federal lender. 

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

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

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

24 amounts sufficient to reduce (by not more than 


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

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

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

5 for a project for capital improvement may not exceed 

6 $5,000,000. 

7 ‘‘(c) FUNDING LIMITATIONS.— 

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

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

12 any time with respect to which guarantees have been 

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

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

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

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

19 ‘‘(d) CAPITAL ASSESSMENT AND PLANNING

20 GRANTS.— 

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

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

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

24 for purposes of capital assessment and business 

25 planning. 


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

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

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

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

7 January 1, 2015.’’. 

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

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

10 by adding at the end the following new paragraph: 

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

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

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

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

16 in— 

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

18 metropolitan statistical area; or 

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

21 under the most recent modification of the 

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

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


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

2 rural, regional, or national referral center under 

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

4 Act; and 

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

6 hospital (as defined in section 

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

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

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

11 under title XVIII of the Social Security Act shall not 

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

14 (c) CONFORMING AMENDMENTS.—Section 1602 of 

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

16 amended— 

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

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

19 (2) in subsection (d)— 

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

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

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

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


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1 SEC. 10. EXTENSION OF MEDICARE INCENTIVE PAYMENT 

2 PROGRAM FOR PHYSICIAN SCARCITY AREAS. 

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

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

5 services furnished on or after April 1, 2014, and before 

6 April 1, 2015’’ after ‘‘2008’’. 

7 SEC. 11. EXTENSION OF FLOOR ON MEDICARE WORK GEO8 GRAPHIC ADJUSTMENT. 

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

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

11 1, 2015’’ and inserting ‘‘January 1, 2016’’. 

12 SEC. 12. RECOGNITION OF ATTENDING PHYSICIAN ASSIST13 ANTS AS ATTENDING PHYSICIANS TO SERVE 

14 HOSPICE PATIENTS. 

15 (a) IN GENERAL.—Section 1861(dd)(3)(B) of the So16 cial Security Act (42 U.S.C. 1395x(dd)(3)(B)) is amend17 ed— 

18 (1) by striking ‘‘or nurse practitioner’’ and in19 serting ‘‘, the nurse practitioner’’; and 

20 (2) by inserting ‘‘, or the physician assistant 

21 (as defined in such subsection)’’ after ‘‘subsection 

22 (aa)(5))’’. 

23 (b) PERMITTING PHYSICIAN ASSISTANTS WHEN

24 DELEGATED BY A PHYSICIAN TO ORDER HOSPICE

25 CARE.—Section 1814(a)(7)(A) of such Act (42 U.S.C. 

26 1395f(a)(7)(A)) is amended— 


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1 (1) in clause (i)(I), by striking ‘‘does not in2 clude a nurse practitioner’’ and inserting ‘‘only in3 cludes a physician assistant if a physician has dele4 gated the authority to make the certification re5 quired under this paragraph to such physician as6 sistant’’; and 

7 (2) by amending clause (ii) to read as follows: 

8 ‘‘(ii) in a subsequent 90- or 60-day 

9 period— 

10 ‘‘(I) the medical director or phy11 sician described in clause (i)(II); 

12 ‘‘(II) a physician employed by the 

13 hospice program providing (or arrang14 ing for) the care or providing care to 

15 the individual under arrangement with 

16 such hospice program; 

17 ‘‘(III) a nurse practitioner em18 ployed by such hospice program or 

19 providing care to the individual under 

20 arrangement with such hospice pro21 gram; or 

22 ‘‘(IV) a physician assistant em23 ployed by such hospice program or 

24 providing care to the individual under 

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1 gram, provided that an individual de2 scribed in subclause (I) or (II) has 

3 delegated the authority to make the 

4 recertification required under this 

5 clause to such physician assistant, 

6 recertifies at the beginning of the period 

7 that the individual is terminally ill based 

8 on such clinical judgment;’’. 

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

10 this section shall apply to items and services furnished on 

11 or after January 1, 2015. 

12 SEC. 13. IMPROVING CARE PLANNING FOR MEDICARE 

13 HOME HEALTH SERVICES. 

14 (a) PART A PROVISIONS.—Section 1814(a) of the So15 cial Security Act (42 U.S.C. 1395f(a)) is amended— 

16 (1) in paragraph (2)— 

17 (A) in the matter preceding subparagraph 

18 (A), by inserting ‘‘, a nurse practitioner or clin19 ical nurse specialist who is working in collabo20 ration with a physician in accordance with 

21 State law, a certified nurse-midwife (as defined 

22 in section 1861(gg)) as authorized by State law, 

23 or a physician assistant (as defined in section 

24 1861(aa)(5)) under the supervision of a physi25 cian’’ after ‘‘1866(j)’’; and 


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1 (B) in subparagraph (C)— 

2 (i) by inserting ‘‘, a nurse practi3 tioner, a clinical nurse specialist, a cer4 tified nurse-midwife, or a physician assist5 ant (as the case may be)’’ after ‘‘physi6 cian’’ the first 2 times it appears; and 

7 (ii) by striking ‘‘, and, in the case of 

8 a certification made by a physician’’ and 

9 all that follows through ‘‘face-to-face en10 counter’’ and inserting ‘‘, and, in the case 

11 of a certification made by a physician after 

12 January 1, 2010, or by a nurse practi13 tioner, clinical nurse specialist, certified 

14 nurse-midwife, or physician assistant (as 

15 the case may be) after January 1, 2015, 

16 prior to making such certification the phy17 sician, nurse practitioner, clinical nurse 

18 specialist, certified nurse-midwife, or physi19 cian assistant must document that the 

20 physician, nurse practitioner, clinical nurse 

21 specialist, certified nurse-midwife, or physi22 cian assistant has had a face-to-face en23 counter’’; and 

24 (2) in the flush matter following paragraph 

25 (8)— 


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1 (A) in the first sentence, by inserting ‘‘cer2 tified nurse-midwife,’’ after ‘‘clinical nurse spe3 cialist,’’; 

4 (B) in the second sentence— 

5 (i) by striking ‘‘physician certifi6 cation’’ and inserting ‘‘certification’’; 

7 (ii) by inserting ‘‘(or on January 1, 

8 2015, in the case of regulations to imple9 ment the amendments made by section 13 

10 of the Craig Thomas Rural Hospital and 

11 Provider Equity Act of 2014)’’ after 

12 ‘‘1981’’; and 

13 (iii) by striking ‘‘a physician who’’ 

14 and inserting ‘‘a physician, nurse practi15 tioner, clinical nurse specialist, certified 

16 nurse-midwife, or physician assistant 

17 who’’; and 

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

19 nurse practitioner, clinical nurse specialist, cer20 tified nurse-midwife, or physician assistant’’ 

21 after ‘‘physician’’. 

22 (b) PART B PROVISIONS.—Section 1835(a) of the So23 cial Security Act (42 U.S.C. 1395n(a)) is amended— 

24 (1) in paragraph (2)— 


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1 (A) in the matter preceding subparagraph 

2 (A), by inserting ‘‘, a nurse practitioner or clin3 ical nurse specialist (as those terms are defined 

4 in section 1861(aa)(5)) who is working in col5 laboration with a physician in accordance with 

6 State law, a certified nurse-midwife (as defined 

7 in section 1861(gg)) as authorized by State law, 

8 or a physician assistant (as defined in section 

9 1861(aa)(5)) under the supervision of a physi10 cian’’ after ‘‘1866(j)’’; and 

11 (B) in subparagraph (A)— 

12 (i) in each of clauses (ii) and (iii) of 

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

14 practitioner, a clinical nurse specialist, a 

15 certified nurse-midwife, or a physician as16 sistant (as the case may be)’’ after ‘‘physi17 cian’’; and 

18 (ii) in clause (iv), by striking ‘‘after 

19 January 1, 2010’’ and all that follows 

20 through ‘‘face-to-face encounter’’ and in21 serting ‘‘made by a physician after Janu22 ary 1, 2010, or by a nurse practitioner, 

23 clinical nurse specialist, certified nurse24 midwife, or physician assistant (as the case 

25 may be) after January 1, 2015, prior to 


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1 making such certification the physician, 

2 nurse practitioner, clinical nurse specialist, 

3 certified nurse-midwife, or physician assist4 ant must document that the physician, 

5 nurse practitioner, clinical nurse specialist, 

6 certified nurse-midwife, or physician assist7 ant has had a face-to-face encounter’’; 

8 (2) in the third sentence, by inserting ‘‘, nurse 

9 practitioner, clinical nurse specialist, certified nurse10 midwife, or physician assistant (as the case may 

11 be)’’ after ‘‘physician’’; 

12 (3) in the fourth sentence— 

13 (A) by striking ‘‘physician certification’’ 

14 and inserting ‘‘certification’’; 

15 (B) by inserting ‘‘(or on January 1, 2015, 

16 in the case of regulations to implement the 

17 amendments made by section 13 of the Craig 

18 Thomas Rural Hospital and Provider Equity 

19 Act of 2014)’’ after ‘‘1981’’; and 

20 (C) by striking ‘‘a physician who’’ and in21 serting ‘‘a physician, nurse practitioner, clinical 

22 nurse specialist, certified nurse-midwife, or phy23 sician assistant who’’; and 


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1 (4) in the fifth sentence, by inserting ‘‘, nurse 

2 practitioner, clinical nurse specialist, certified nurse3 midwife, or physician assistant’’ after ‘‘physician’’. 

4 (c) DEFINITION PROVISIONS.— 

5 (1) HOME HEALTH SERVICES.—Section 

6 1861(m) of the Social Security Act (42 U.S.C. 

7 1395x(m)) is amended— 

8 (A) in the matter preceding paragraph 

9 (1)— 

10 (i) by inserting ‘‘, a nurse practitioner 

11 or a clinical nurse specialist (as those 

12 terms are defined in subsection (aa)(5)), a 

13 certified nurse-midwife (as defined in sec14 tion 1861(gg)), or a physician assistant (as 

15 defined in subsection (aa)(5))’’ after ‘‘phy16 sician’’ the first place it appears; and 

17 (ii) by inserting ‘‘, a nurse practi18 tioner, a clinical nurse specialist, a cer19 tified nurse-midwife, or a physician assist20 ant’’ after ‘‘physician’’ the second place it 

21 appears; and 

22 (B) in paragraph (3), by inserting ‘‘, a 

23 nurse practitioner, a clinical nurse specialist, a 

24 certified nurse-midwife, or a physician assist25 ant’’ after ‘‘physician’’. 


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1 (2) HOME HEALTH AGENCY.—Section 

2 1861(o)(2) of the Social Security Act (42 U.S.C. 

3 1395x(o)(2)) is amended— 

4 (A) by inserting ‘‘, nurse practitioners or 

5 clinical nurse specialists (as those terms are de6 fined in subsection (aa)(5)), certified nurse-mid7 wives (as defined in section 1861(gg)), or physi8 cian assistants (as defined in subsection 

9 (aa)(5))’’ after ‘‘physicians’’; and 

10 (B) by inserting ‘‘, nurse practitioner, clin11 ical nurse specialist, certified nurse-midwife, 

12 physician assistant,’’ after ‘‘physician’’. 

13 (d) HOME HEALTH PROSPECTIVE PAYMENT SYSTEM

14 PROVISIONS.—Section 1895 of the Social Security Act (42 

15 U.S.C. 1395fff) is amended— 

16 (1) in subsection (c)(1), by inserting ‘‘, the 

17 nurse practitioner or clinical nurse specialist (as 

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

19 certified nurse-midwife (as defined in section 

20 1861(gg)), or the physician assistant (as defined in 

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

22 (2) in subsection (e)— 

23 (A) in paragraph (1)(A), by inserting ‘‘, a 

24 nurse practitioner or clinical nurse specialist (as 

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


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1 a certified nurse-midwife (as defined in section 

2 1861(gg)), or a physician assistant (as defined 

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

4 (B) in paragraph (2)— 

5 (i) in the heading, by striking ‘‘PHY6 SICIAN CERTIFICATION’’ and inserting 

7 ‘‘RULE OF CONSTRUCTION REGARDING RE8 QUIREMENT FOR CERTIFICATION’’; and 

9 (ii) by striking ‘‘physician’’. 

10 (e) EFFECTIVE DATE.—The amendments made by 

11 this section shall apply to items and services furnished on 

12 or after January 1, 2015. 

13 SEC. 14. RURAL HEALTH CLINIC IMPROVEMENTS. 

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

15 1395l(f)) is amended— 

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

17 end and inserting a semicolon; 

18 (2) in paragraph (2)— 

19 (A) by inserting ‘‘(before 2015)’’ after ‘‘in 

20 a subsequent year’’; and 

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

22 inserting a semicolon; and 

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

24 paragraphs: 

25 ‘‘(3) in 2015, at $101 per visit; and 


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1 ‘‘(4) for years following 2015, at the limit es2 tablished under this subsection for the previous year 

3 increased by the percentage increase in the MEI (as 

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

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

6 SEC. 15. TEMPORARY MEDICARE PAYMENT INCREASE FOR 

7 HOME HEALTH SERVICES FURNISHED IN A 

8 RURAL AREA. 

9 Section 421(a) of the Medicare Prescription Drug, 

10 Improvement, and Modernization Act of 2003 (Public Law 

11 108–173; 117 Stat. 2283), as amended by section 5201(b) 

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

13 171; 120 Stat. 46) and section 3131(c) of the Patient Pro14 tection and Affordable Care Act (Public Law 111–148; 

15 124 Stat. 428), is amended by striking ‘‘January 1, 2016, 

16 3 percent’’ and inserting ‘‘April 1, 2014, and episodes and 

17 visits ending on or after April 1, 2015, and before January 

18 1, 2016, 3 percent’’. 

19 SEC. 16. EXTENSION OF INCREASED MEDICARE PAYMENTS 

20 FOR RURAL GROUND AMBULANCE SERVICES. 

21 (a) IN GENERAL.—Section 1834(l)(13)(A)(i) of the 

22 Social Security Act (42 U.S.C. 1395m(l)(13)(A)(i)) is 

23 amended by striking ‘‘before April 1, 2015’’ and inserting 

24 ‘‘before April 1, 2014, or 5 percent if such service is furVerDate Mar 15 2010 01:08 May 23, 2014 Jkt 039200 PO 00000 Frm 00024 Fmt 6652 Sfmt 6201 E:\BILLS\S2359.IS S2359

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1 nished on or after April 1, 2014, and before January 1, 

2 2016’’. 

3 (b) SUPER RURAL AMBULANCE.—Section 

4 1834(l)(12)(A) of the Social Security Act (42 U.S.C. 

5 1395m(l)(12)(A)) is amended by striking ‘‘April 1, 2015’’ 

6 and inserting ‘‘January 1, 2016’’. 

7 SEC. 17. COVERAGE OF MARRIAGE AND FAMILY THERAPIST 

8 SERVICES AND MENTAL HEALTH COUNSELOR 

9 SERVICES UNDER PART B OF THE MEDICARE 

10 PROGRAM. 

11 (a) COVERAGE OF SERVICES.— 

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

13 Social Security Act (42 U.S.C. 1395x(s)(2)) is 

14 amended— 

15 (A) in subparagraph (EE), by striking 

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

17 (B) in subparagraph (FF), by inserting 

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

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

20 subparagraph: 

21 ‘‘(GG) marriage and family therapist services 

22 (as defined in subsection (iii)(1)) and mental health 

23 counselor services (as defined in subsection 

24 (iii)(3));’’. 


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

2 Security Act (42 U.S.C. 1395x) is amended by add3 ing at the end the following new subsection: 

4 ‘‘Marriage and Family Therapist Services; Marriage and 

5 Family Therapist; Mental Health Counselor Serv6 ices; Mental Health Counselor 

7 ‘‘(iii)(1) The term ‘marriage and family therapist 

8 services’ means services performed by a marriage and 

9 family therapist (as defined in paragraph (2)) for the diag10 nosis and treatment of mental illnesses, which the mar11 riage and family therapist is legally authorized to perform 

12 under State law (or the State regulatory mechanism pro13 vided by State law) of the State in which such services 

14 are performed, as would otherwise be covered if furnished 

15 by a physician or as an incident to a physician’s profes16 sional service, but only if no facility or other provider 

17 charges or is paid any amounts with respect to the fur18 nishing of such services. 

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

20 an individual who— 

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

22 which qualifies for licensure or certification as a 

23 marriage and family therapist pursuant to State 

24 law; 


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

2 at least 2 years of clinical supervised experience in 

3 marriage and family therapy; and 

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

5 services in a State that provides for licensure or cer6 tification of marriage and family therapists, is li7 censed or certified as a marriage and family thera8 pist in such State. 

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

10 means services performed by a mental health counselor (as 

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

12 of mental illnesses which the mental health counselor is 

13 legally authorized to perform under State law (or the 

14 State regulatory mechanism provided by the State law) of 

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

16 otherwise be covered if furnished by a physician or as inci17 dent to a physician’s professional service, but only if no 

18 facility or other provider charges or is paid any amounts 

19 with respect to the furnishing of such services. 

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

21 individual who— 

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

23 mental health counseling or a related field; 


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1 ‘‘(B) after obtaining such a degree has per2 formed at least 2 years of supervised mental health 

3 counselor practice; and 

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

5 services in a State that provides for licensure or cer6 tification of mental health counselors or professional 

7 counselors, is licensed or certified as a mental health 

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

9 (3) PROVISION FOR PAYMENT UNDER PART

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

11 Act (42 U.S.C. 1395k(a)(2)(B)) is amended by add12 ing at the end the following new clause: 

13 ‘‘(v) marriage and family therapist 

14 services (as defined in section 1861(iii)(1)) 

15 and mental health counselor services (as 

16 defined in section 1861(iii)(3));’’. 

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

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

19 is amended— 

20 (A) by striking ‘‘and (Z)’’ and inserting 

21 ‘‘(Z)’’; and 

22 (B) by inserting before the semicolon at 

23 the end the following: ‘‘, and (AA) with respect 

24 to marriage and family therapist services and 

25 mental health counselor services under section 


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1 1861(s)(2)(GG), the amounts paid shall be 80 

2 percent of the lesser of the actual charge for 

3 the services or 75 percent of the amount deter4 mined for payment of a psychologist under sub5 paragraph (L)’’. 

6 (5) EXCLUSION OF MARRIAGE AND FAMILY

7 THERAPIST SERVICES AND MENTAL HEALTH COUN8 SELOR SERVICES FROM SKILLED NURSING FACILITY

9 PROSPECTIVE PAYMENT SYSTEM.—Section 

10 1888(e)(2)(A)(ii) of the Social Security Act (42 

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

12 ‘‘marriage and family therapist services (as defined 

13 in section 1861(iii)(1)), mental health counselor 

14 services (as defined in section 1861(iii)(3)),’’ after 

15 ‘‘qualified psychologist services,’’. 

16 (6) INCLUSION OF MARRIAGE AND FAMILY

17 THERAPISTS AND MENTAL HEALTH COUNSELORS AS

18 PRACTITIONERS FOR ASSIGNMENT OF CLAIMS.—Sec19 tion 1842(b)(18)(C) of the Social Security Act (42 

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

21 the end the following new clauses: 

22 ‘‘(vii) A marriage and family therapist (as de23 fined in section 1861(iii)(2)). 

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

25 section 1861(iii)(4)).’’. 


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1 (b) COVERAGE OF CERTAIN MENTAL HEALTH SERV2 ICES PROVIDED IN CERTAIN SETTINGS.— 

3 (1) RURAL HEALTH CLINICS AND FEDERALLY

4 QUALIFIED HEALTH CENTERS.—Section 

5 1861(aa)(1)(B) of the Social Security Act (42 

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

7 by a clinical social worker (as defined in subsection 

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

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

10 and family therapist (as defined in subsection 

11 (iii)(2)), or by a mental health counselor (as defined 

12 in subsection (iii)(4))’’. 

13 (2) HOSPICE PROGRAMS.—Section 

14 1861(dd)(2)(B)(i)(III) of the Social Security Act (42 

15 U.S.C. 1395x(dd)(2)(B)(i)(III)) is amended by in16 serting ‘‘, marriage and family therapist, or mental 

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

18 (c) AUTHORIZATION OF MARRIAGE AND FAMILY

19 THERAPISTS AND MENTAL HEALTH COUNSELORS TO

20 DEVELOP DISCHARGE PLANS FOR POST-HOSPITAL SERV21 ICES.—Section 1861(ee)(2)(G) of the Social Security Act 

22 (42 U.S.C. 1395x(ee)(2)(G)) is amended by inserting ‘‘, 

23 including a marriage and family therapist and a mental 

24 health counselor who meets qualification standards estab25 lished by the Secretary’’ before the period at the end. 


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

2 this section shall apply with respect to services furnished 

3 on or after January 1, 2015. 

4 SEC. 18. EXTENSION OF PAYMENT FOR TECHNICAL COMPO5 NENT OF CERTAIN PHYSICIAN PATHOLOGY 

6 SERVICES. 

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

8 SCHIP Benefits Improvement and Protection Act of 2000 

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

10 554), as amended by section 732 of the Medicare Prescrip11 tion Drug, Improvement, and Modernization Act of 2003 

12 (42 U.S.C. 1395w–4 note), section 104 of division B of 

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

14 1395w–4 note), section 104 of the Medicare, Medicaid, 

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

16 173), section 136 of the Medicare Improvements for Pa17 tients and Providers Act of 2008 (Public Law 110–275), 

18 section 3104 of the Patient Protection and Affordable 

19 Care Act (Public Law 111–148), and section 105 of the 

20 Medicare and Medicaid Extenders Act of 2010 (Public 

21 Law 111–309), is amended by striking ‘‘2010, and 2011’’ 

22 and inserting ‘‘2010, 2011, the portion of fiscal year 2014 

23 after April 1, 2014, and the portion of fiscal year 2015 

24 before April 1, 2015’’. 


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1 SEC. 19. FACILITATING THE PROVISION OF TELEHEALTH 

2 SERVICES ACROSS STATE LINES. 

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

4 provision of telehealth services, for which payment is made 

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

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

10 practitioner practice across State lines. 

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

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

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

16 (2) PHYSICIAN, PRACTITIONER.—The terms 

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

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

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

21 program’’ means the program of health insurance 

22 administered by the Secretary of Health and Human 

23 Services under title XVIII of the Social Security Act 

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


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1 SEC. 20. MEDICARE PART A PAYMENT FOR ANESTHESIOL2 OGIST SERVICES IN CERTAIN RURAL HOS3 PITALS BASED ON CRNA PASS-THROUGH 

4 RULES. 

5 (a) IN GENERAL.—Section 1814 of the Social Secu6 rity Act (42 U.S.C. 1395f) is amended by adding at the 

7 end the following new subsection: 

8 ‘‘Anesthesiologist Services Provided in Certain Rural 

9 Hospitals 

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

11 title, coverage and payment shall be provided under this 

12 part for physicians’ services that are anesthesia services 

13 furnished by a physician who is an anesthesiologist in a 

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

15 manner as payment is made under the exception provided 

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

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

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

19 Omnibus Budget Reconciliation Act of 1989, (relating to 

20 payment on a reasonable cost, pass-through basis) for cer21 tified registered nurse anesthetist services furnished by a 

22 certified registered nurse anesthetist in a hospital de23 scribed in such section 9320(k). 

24 ‘‘(2) No payment shall be made under any other pro25 vision of this title for physicians’ services for which pay26 ment is made under this subsection. 


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

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

3 Budget Reconciliation Act of 1986, as so added and 

4 amended, except that— 

5 ‘‘(A) any reference in such section to a ‘cer6 tified registered nurse anesthetist’ or an ‘anesthetist’ 

7 is deemed a reference to a ‘physician who is an anes8 thesiologist’ or an ‘anesthesiologist’, respectively; 

9 and 

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

11 ‘1987’ is deemed a reference to such date and year 

12 as the Secretary shall specify.’’. 

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

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

15 reporting periods beginning on or after the date of the 

16 enactment of this Act. 

17 SEC. 21. TEMPORARY FLOOR ON THE PRACTICE EXPENSE 

18 GEOGRAPHIC INDEX FOR SERVICES FUR19 NISHED IN RURAL AREAS OUTSIDE OF FRON20 TIER STATES UNDER THE MEDICARE PHYSI21 CIAN FEE SCHEDULE. 

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

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

24 the following new subparagraph: 


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1 ‘‘(J) FLOOR AT 1.0 ON PRACTICE EXPENSE

2 GEOGRAPHIC INDEX FOR SERVICES FURNISHED

3 IN RURAL AREAS OUTSIDE OF FRONTIER

4 STATES.—For purposes of payment for services 

5 furnished in a rural area (other than a rural 

6 area located in a State to which subparagraph 

7 (I) applies) on or after April 1, 2014, and be8 fore April 1, 2015, after calculating the practice 

9 expense index under subparagraph (A)(i), the 

10 Secretary shall increase any such index to 1.0 

11 if such index would otherwise be less than 1.0. 

12 The preceding sentence shall not be applied in 

13 a budget neutral manner.’’. 

14 SEC. 22. REVISIONS TO STANDARD FOR DESIGNATION OF 

15 SOLE COMMUNITY HOSPITALS. 

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

17 (42 U.S.C. 1395ww(d)(5)(D)(iv)) is amended by adding 

18 at the end the following new sentence: ‘‘Under such stand19 ard, the time required for an individual to travel to the 

20 nearest alternative source of care shall be measured over 

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

22 Government entity for use by the general public which is 

23 the most expeditious and accessible route as designated 

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


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1 SEC. 23. MEDICARE TREATMENT OF STANDBY AND ON2 CALL TIME FOR CRNA SERVICES. 

3 (a) IN GENERAL.—Section 9320(k) of the Omnibus 

4 Budget Reconciliation Act of 1986 (42 U.S.C. 1395k 

5 note), as added by section 608(c)(2) of the Family Sup6 port Act of 1988 and amended by section 6132 of the Om7 nibus Budget Reconciliation Act of 1989, is amended by 

8 adding at the end the following: 

9 ‘‘(3) In determining the reasonable costs in10 curred by a hospital or critical access hospital for 

11 the services of a certified registered nurse anes12 thetist under this subsection, the Secretary shall in13 clude standby costs and on-call costs incurred by the 

14 hospital or critical access hospital, respectively, with 

15 respect to such nurse anesthetist.’’. 

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

17 subsection (a) shall apply to costs incurred in cost report18 ing periods beginning in fiscal years after fiscal year 2005 

19 and before fiscal year 2015. 

20 SEC. 24. STATE OFFICES OF RURAL HEALTH. 

21 Section 338J(j)(1) of the Public Health Service Act 

22 (42 U.S.C. 254r(j)(1)) is amended by inserting ‘‘and 2015 

23 through 2016’’ before the period. 


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1 SEC. 25. REMOVING MEDICARE 96-HOUR PHYSICIAN CER2 TIFICATION REQUIREMENT FOR INPATIENT 

3 CRITICAL ACCESS HOSPITAL SERVICES. 

4 (a) IN GENERAL.—Section 1814(a) of the Social Se5 curity Act (42 U.S.C. 1395f(a)), as amended by sections 

6 12 and 13, is further amended— 

7 (1) in paragraph (6), by adding ‘‘and’’ at the 

8 end; 

9 (2) in paragraph (7), at the end of subpara10 graph (D)(ii), by striking ‘‘; and’’ and inserting a 

11 period; and 

12 (3) by striking paragraph (8). 

13 (b) APPLICATION.—The amendments made by sub14 section (a) shall apply with respect to items and services 

15 furnished on or after January 1, 2014. 

16 SEC. 26. EXTENSION OF ENFORCEMENT INSTRUCTION ON 

17 SUPERVISION REQUIREMENTS FOR OUT18 PATIENT THERAPEUTIC SERVICES IN CRIT19 ICAL ACCESS AND SMALL RURAL HOSPITALS 

20 THROUGH 2014. 

21 The Secretary of Health and Human Services shall 

22 continue to apply through calendar year 2014 the enforce23 ment instruction described in the notice of the Centers for 

24 Medicare & Medicaid Services entitled ‘‘Enforcement In25 struction on Supervision Requirements for Outpatient 

26 Therapeutic Services in Critical Access and Small Rural 


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1 Hospitals for CY 2013’’, dated November 1, 2012 (pro2 viding for an exception to the restatement and clarification 

3 under the final rulemaking changes to the Medicare hos4 pital outpatient prospective payment system and calendar 

5 year 2009 payment rates (published in the Federal Reg6 ister on November 18, 2008, 73 Fed. Reg. 68702 through 

7 68704) with respect to requirements for direct supervision 

8 by physicians for therapeutic hospital outpatient services). 

Æ 


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