II 

109TH CONGRESS 

1ST SESSION S. 647 

To amend title XVIII of the Social Security Act to authorize physical therapists to evaluate and treat medicare beneficiaries without a requirement 

for a physician referral, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

MARCH 17, 2005 

Mrs. LINCOLN (for herself, Mr. SPECTER, Mr. ENSIGN, Ms. LANDRIEU, and 

Mr. DAYTON) 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 authorize 

physical therapists to evaluate and treat medicare beneficiaries without a requirement for a physician referral, 

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. 

4 This Act may be cited as the ‘‘Medicare Patient Ac5 cess to Physical Therapists Act of 2005’’. 
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1 SEC. 2. ACCESS TO OUTPATIENT PHYSICAL THERAPY SERV2 ICES FOR MEDICARE BENEFICIARIES AS AU3 THORIZED BY STATE LAW. 

4 (a) IN GENERAL.— 

5 (1) ELIMINATION OF REQUIRED PHYSICIAN RE6 FERRAL.— 

7 (A) DEFINITION OF OUTPATIENT PHYS8 ICAL THERAPY SERVICES.—Section 1861(p) of 

9 the Social Security Act (42 U.S.C. 1395x(p)) is 

10 amended— 

11 (i) in the matter preceding paragraph 

12 (1), by striking ‘‘as an outpatient’’; 

13 (ii) by amending paragraph (1) to 

14 read as follows: 

15 ‘‘(1) who is an outpatient, and’’; 

16 (iii) in paragraph (2)— 

17 (I) by striking ‘‘physician (as so 

18 defined) or by a qualified physical 

19 therapist’’ and inserting ‘‘physician 

20 (as defined in paragraph (1), (3), or 

21 (4) of subsection (r)) or by a qualified 

22 physical therapist (as defined in sec23 tion 1861(bbb))’’; and 

24 (II) by inserting ‘‘or a qualified 

25 physical therapist (as so defined)’’ 
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1 after ‘‘physician’’ the second place it 

2 appears; 

3 (iv) in paragraph (4)(A)(ii), by strik4 ing ‘‘one or more’’ and all that follows 

5 through ‘‘agency) and’’; and 

6 (v) by amending the fifth sentence to 

7 read as follows: ‘‘Nothing in this sub8 section shall be construed as authorizing 

9 the provision of services in a State that a 

10 qualified physical therapist is not author11 ized to provide in the State in accordance 

12 with State law (or the State regulatory 

13 mechanism provided by State law). 

14 (B) CONFORMING AMENDMENTS.—Section 

15 1835(a)(2) of the Social Security Act (42 

16 U.S.C. 1395n(a)(2)) is amended— 

17 (i) in the matter preceding subpara18 graph (A), by inserting ‘‘, or in the case of 

19 outpatient physical therapy services (as de20 scribed in subparagraph (C)) and physical 

21 therapy services furnished as comprehen22 sive outpatient rehabilitation facility serv23 ices (described in subparagraph (E)), a 

24 qualified physical therapist,’’ after ‘‘a phy25 sician’’; 
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1 (ii) in subparagraph (C)— 

2 (I) in the matter preceding clause 

3 (i), by striking ‘‘or outpatient occupa4 tional therapy services’’; 

5 (II) in clause (i), by striking ‘‘or 

6 occupational therapy services, respec7 tively,’’ and inserting ‘‘, and’’; 

8 (III) in clause (ii), by striking 

9 ‘‘or qualified occupational therapist, 

10 respectively,’’; and 

11 (IV) beginning in clause (ii), by 

12 striking ‘‘by a physician, and (iii)’’ 

13 and all that follows and inserting ‘‘by 

14 a physician or a qualified physical 

15 therapist;’’; 

16 (iii) in subparagraph (D)— 

17 (I) in the matter preceding clause 

18 (i), by striking ‘‘outpatient speech pa19 thology services’’ and inserting ‘‘out20 patient occupational therapy services 

21 or outpatient speech-language pathol22 ogy services’’; 

23 (II) in clause (i), by striking 

24 ‘‘needed speech pathology services’’ 

25 and inserting ‘‘needed occupational 
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1 therapy services or speech-language 

2 pathology services, respectively’’; and 

3 (III) in clause (ii), by striking 

4 ‘‘speech pathologist’’ and inserting 

5 ‘‘occupational therapist or speech-lan6 guage pathologist, respectively,’’; and 

7 (iv) in subparagraph (E)— 

8 (I) in clause (ii), by inserting 

9 ‘‘(or, in the case of comprehensive 

10 outpatient rehabilitation facility serv11 ices consisting of physical therapy 

12 services, by a qualified physical thera13 pist)’’ after ‘‘physician’’; and 

14 (II) in clause (iii), by inserting 

15 ‘‘in the case of comprehensive out16 patient rehabilitation facility services 

17 not consisting of physical therapy 

18 services,’’ before ‘‘such services’’. 

19 (2) DEFINITION OF QUALIFIED PHYSICAL

20 THERAPIST.—Section 1861 of the Social Security 

21 Act (42 U.S.C. 1395x) is amended by adding at the 

22 end the following new subsection: 

23 ‘‘Qualified Physical Therapist 

24 ‘‘(bbb) The term ‘qualified physical therapist’ means 

25 an individual who is licensed as a physical therapist by 
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1 the State in which such individual is practicing and who 

2 meets the applicable requirements under paragraph (1) or 

3 (2): 

4 ‘‘(1) With respect to individuals graduating 

5 from a professional physical therapy education pro6 gram on or after January 1, 2003, the individual— 

7 ‘‘(A) has received a master’s or doctoral 

8 degree from a professional physical therapy 

9 education program that has been accredited by 

10 a national physical therapy education accredita11 tion agency recognized by the Secretary of Edu12 cation; or 

13 ‘‘(B) has graduated from a professional 

14 physical therapy education program outside the 

15 United States with a curriculum that is sub16 stantially equivalent (as determined by an ac17 creditation agency described in subparagraph 

18 (A)) to the curricula of programs for profes19 sional physical therapy education programs in 

20 the United States that are accredited by such 

21 an accreditation agency. 

22 ‘‘(2) With respect to individuals licensed as 

23 physical therapists by a State before 2003, the indi24 vidual was, or upon application to the Secretary 

25 could have been, qualified under regulations of the 
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1 Secretary in effect before such date to furnish phys2 ical therapy services under this title, as determined 

3 by the Secretary.’’. 

4 (b) PRESERVING EXISTING LAW FOR OUTPATIENT

5 OCCUPATIONAL THERAPY SERVICES.— 

6 (1) DEFINITION.—Section 1861(g) of the Social 

7 Security Act (42 U.S.C. 1395x(g)) is amended to 

8 read as follows: 

9 ‘‘Outpatient Occupational Therapy Services 

10 ‘‘(g) The term ‘outpatient occupational therapy serv11 ices’ means occupational therapy services furnished by a 

12 provider of services, a clinic, a rehabilitation agency, or 

13 a public health agency, or by others under an arrangement 

14 with, and under the supervision of, such a provider, clinic, 

15 rehabilitation agency, or public health agency to an indi16 vidual as an outpatient— 

17 ‘‘(1) who is under the care of a physician (as 

18 defined in paragraph (1), (3), or (4) of subsection 

19 (r)); 

20 ‘‘(2) with respect to whom a plan prescribing 

21 the type, amount, and duration of occupational ther22 apy services that are furnished to such individual 

23 has been established by a physician (as so defined) 

24 or by an occupational therapist and is periodically 

25 reviewed by a physician (as so defined); 
8 

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1 excluding, however— 

2 ‘‘(3) any item or service if it would not be in3 cluded under subsection (b) if furnished to an inpa4 tient of a hospital; and 

5 ‘‘(4) any such service— 

6 ‘‘(A) if furnished by a clinic, rehabilitation 

7 agency, or by others under arrangements with 

8 such clinic or agency, unless such clinic or reha9 bilitation agency— 

10 ‘‘(i) provides an adequate program of 

11 occupational therapy services for out12 patients and has the facilities and per13 sonnel required for such program or re14 quired for the supervision of such a pro15 gram, in accordance with such require16 ments as the Secretary may specify; 

17 ‘‘(ii) has policies, established by a 

18 group of professional personnel, including 

19 one or more occupational therapists, to 

20 govern the services (referred to in clause 

21 (i)) it provides; 

22 ‘‘(iii) maintains clinical records on all 

23 patients; 

24 ‘‘(iv) if such clinic or agency is situ25 ated in a State in which State or applica-
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1 ble local law provides for the licensing of 

2 institutions of this nature— 

3 ‘‘(I) is licensed pursuant to such 

4 law, or 

5 ‘‘(II) is approved by the agency 

6 of such State or locality responsible 

7 for licensing institutions of this na8 ture, as meeting the standards estab9 lished for such licensing; and 

10 ‘‘(v) meets such other conditions relat11 ing to the health and safety of individuals 

12 who are furnished services by such clinic or 

13 agency on an outpatient basis, as the Sec14 retary may find necessary, and provides 

15 the Secretary on a continuing basis with a 

16 surety bond that is not less than $50,000; 

17 or 

18 ‘‘(B) if furnished by a public health agen19 cy, unless such agency meets such other condi20 tions relating to the safety of individuals who 

21 are furnished services by such agency on an 

22 outpatient basis, as the Secretary may find nec23 essary. 

24 The term ‘outpatient occupational therapy services’ also 

25 includes occupational therapy services furnished an indi-
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1 vidual by an occupational therapist (in the office of the 

2 occupational therapist or in such individual’s home) who 

3 meets licensing and other standards prescribed by the Sec4 retary in regulations, otherwise than under an arrange5 ment with and under the supervision of a provider of serv6 ices, clinic, rehabilitation agency, or public health agency, 

7 if the furnishing of such services meets such conditions 

8 relating to health and safety as the Secretary may find 

9 necessary. In addition, such term includes occupational 

10 therapy services that meet the requirements of the first 

11 sentence of this subsection except that they are furnished 

12 to an inpatient of a hospital or extended care facility. 

13 Nothing in this subsection shall be construed as requiring, 

14 with respect to outpatients who are not entitled to benefits 

15 under this title, an occupational therapist to provide out16 patient occupational therapy services only to outpatients 

17 who are under the care of a physician or pursuant to a 

18 plan of care established by a physician. The Secretary may 

19 waive the requirement of a surety bond under paragraph 

20 (4)(A)(v) in the case of a clinic or agency that provides 

21 a comparable surety bond under State law.’’. 

22 (2) CONFORMING AMENDMENTS.— 

23 (A) SCOPE OF BENEFITS.—Section 

24 1832(a)(2)(C) of the Social Security Act (42 

25 U.S.C. 1395k(a)(2)(C)) is amended by striking 
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1 ‘‘such sentence applies through the operation of 

2 section 1861(g))’’ and inserting ‘‘the second 

3 sentence of section 1861(g) applies)’’. 

4 (B) PAYMENT OF BENEFITS.—Section 

5 1833(g)(3) of the Social Security Act (42 

6 U.S.C. 1395l(g)(3)) is amended by striking 

7 ‘‘section 1861(p)’’ and all that follows through 

8 ‘‘section 1861(g)’’ and inserting ‘‘section 

9 1861(g) (but not described in subsection 

10 (a)(8)(B))’’. 

11 (C) PROVIDER CLAIMS PROCEDURES.—The 

12 second sentence of section 1835(a) of the Social 

13 Security Act (42 U.S.C. 1395n(a)) is amend14 ed— 

15 (i) by striking ‘‘section 1861(p)(4)(A) 

16 (or meets the requirements of such section 

17 through the operation of section 1861(g))’’ 

18 and inserting ‘‘section 1861(p)(4)(A) or 

19 section 1861(g)(4)(A)’’; 

20 (ii) by striking ‘‘section 1861(p)(4)(B) 

21 (or meets the requirements of such section 

22 through the operation of section 1861(g))’’ 

23 and inserting ‘‘section 1861(p)(4)(B) or 

24 section 1861(g)(4)(B)’’; and 
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1 (iii) by striking ‘‘(as therein defined) 

2 or (through the operation of section 

3 1861(g)) with respect to the furnishing of 

4 outpatient occupational therapy services’’ 

5 and inserting ‘‘(as defined in section 

6 1861(p)) or outpatient occupational ther7 apy services (as defined in section 

8 1861(g)), respectively’’. 

9 (D) AGREEMENTS WITH PROVIDERS.—Sec10 tion 1866(e)(1) of the Social Security Act (42 

11 U.S.C. 1395cc(e)(1)) is amended— 

12 (i) by striking ‘‘section 1861(p)(4)(A) 

13 (or meets the requirements of such section 

14 through the operation of section 1861(g))’’ 

15 and inserting ‘‘section 1861(p)(4)(A) or 

16 section 1861(g)(4)(A)’’; 

17 (ii) by striking ‘‘section 1861(p)(4)(B) 

18 (or meets the requirements of such section 

19 through the operation of section 1861(g))’’ 

20 and inserting ‘‘section 1861(p)(4)(B) or 

21 section 1861(g)(4)(B)’’; and 

22 (iii) by striking ‘‘(as therein defined) 

23 or (through the operation of section 

24 1861(g)) with respect to the furnishing of 

25 outpatient occupational therapy services’’ 
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1 and inserting ‘‘(as defined in section 

2 1861(p)) or outpatient occupational ther3 apy services (as defined in section 

4 1861(g)), respectively’’. 

5 (c) SEPARATE STATUTORY TREATMENT FOR OUT6 PATIENT PHYSICAL THERAPY SERVICES AND OUT7 PATIENT SPEECH-LANGUAGE PATHOLOGY SERVICES.— 

8 (1) SCOPE OF BENEFITS.—Section 

9 1832(a)(2)(C) of the Social Security Act (42 U.S.C. 

10 1395k(a)(2)(C)), as amended by subsection 

11 (b)(2)(A), is amended— 

12 (A) by striking ‘‘and outpatient’’ and in13 serting ‘‘, outpatient’’; and 

14 (B) by inserting before the semicolon the 

15 following: ‘‘, and outpatient speech-language pa16 thology services’’. 

17 (2) PAYMENT OF BENEFITS.—Section 1833 of 

18 the Social Security Act (42 U.S.C. 1395l) is amend19 ed— 

20 (A) in subparagraphs (A) and (B) of sub21 section (a)(8), by striking ‘‘services, (which in22 cludes outpatient speech-language pathology 

23 services) and outpatient occupational therapy 

24 services’’ each place it appears and inserting 

25 ‘‘services, outpatient occupational therapy serv-
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1 ices, and outpatient speech-language pathology 

2 services’’; and 

3 (B) in subsection (g)— 

4 (i) in paragraphs (1) and (3), by 

5 striking ‘‘paragraph (4)’’ each place it ap6 pears and inserting ‘‘paragraph (5)’’; and 

7 (ii) by redesignating paragraph (4) as 

8 paragraph (5) and inserting after para9 graph (3) the following new paragraph: 

10 ‘‘(4) Subject to paragraph (5), in the case of 

11 speech-language pathology services (of the type de12 scribed in section 1861(ll)(4) (but not described in 

13 subsection (a)(8)(B)) and speech-language pathology 

14 services of such type that are furnished by a physi15 cian or as incident to physicians’ services), with re16 spect to expenses incurred in any calendar year, no 

17 more than the amount specified in paragraph (2) for 

18 the year shall be considered as incurred expenses for 

19 purposes of subsections (a) and (b).’’. 

20 (3) PROVIDER CLAIMS PROCEDURES.—The sec21 ond sentence of section 1835(a) of the Social Secu22 rity Act (42 U.S.C. 1395n(a)), as amended by sub23 section (b)(2)(C), is amended— 
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1 (A) by striking ‘‘or section 1861(g)(4)(A)’’ 

2 and inserting ‘‘, section 1861(g)(4)(A), or sec3 tion 1861(ll)(5)(A)’’; 

4 (B) by striking ‘‘or section 1861(g)(4)(B)’’ 

5 and inserting ‘‘, section 1861(g)(4)(B), or sec6 tion 1861(ll)(4)(B)(ii)(II)’’; and 

7 (C) by striking ‘‘or outpatient occupational 

8 services (as defined in section 1861(g))’’ and 

9 inserting ‘‘, outpatient occupational services (as 

10 defined in section 1861(g)), or outpatient 

11 speech-language pathology services (as defined 

12 in section 1861(ll)(4)(A))’’. 

13 (4) AGREEMENTS WITH PROVIDERS.—Section 

14 1866(e)(1) of the Social Security Act (42 U.S.C. 

15 1395cc(e)(1)), as amended by subsection (b)(2)(D), 

16 is amended— 

17 (A) by striking ‘‘or section 1861(g)(4)(A)’’ 

18 and inserting 1861(g)(4)(A), or section 

19 1861(ll)(5)(A)’’; 

20 (B) by striking ‘‘or section 1861(g)(4)(B)’’ 

21 and inserting ‘‘, section 1861(g)(4)(B), or sec22 tion 1861(ll)(4)(B)(ii)(II)’’; and 

23 (C) by striking ‘‘or outpatient occupational 

24 services (as defined in section 1861(g))’’ and 

25 inserting ‘‘, outpatient occupational services (as 
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1 defined in section 1861(g)), or outpatient 

2 speech-language pathology services (as defined 

3 in section 1861(ll)(4)(A))’’. 

4 (5) DEFINITIONS.—Section 1861 of the Social 

5 Security Act (42 U.S.C. 1395x) is amended— 

6 (A) in subsection (p), by striking the 

7 fourth sentence; 

8 (B) in subsection (s)(2)(D), by striking 

9 ‘‘services and outpatient occupational therapy 

10 services’’ and inserting ‘‘services, outpatient oc11 cupational therapy services, and outpatient 

12 speech-language pathology services’’; and 

13 (C) in subsection (ll), by adding at the end 

14 the following new paragraphs: 

15 ‘‘(4)(A) Subject to subparagraph (B), the term ‘out16 patient speech-language pathology services’ means speech17 language pathology services that are furnished by a pro18 vider of services, a clinic, a rehabilitation agency, or a pub19 lic health agency, or by others under an arrangement with, 

20 and under the supervision of, such provider, clinic, reha21 bilitation agency, or public health agency to an individual 

22 as an outpatient— 

23 ‘‘(i) who is under the care of a physician (as de24 fined in paragraph (1), (3), or (4) of subsection (r)); 

25 and 
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1 ‘‘(ii) with respect to whom a plan prescribing 

2 the type, amount, and duration of speech-language 

3 pathology services that are furnished to such indi4 vidual has been established by a physician (as so de5 fined) or by a qualified speech-language pathologist 

6 and is periodically reviewed by a physician (as so de7 fined). 

8 ‘‘(B) Such term does not include— 

9 ‘‘(i) any item or service if it would not be in10 cluded under subsection (b) if furnished to an inpa11 tient of a hospital; or 

12 ‘‘(ii) any item or service— 

13 ‘‘(I) if furnished by a clinic, rehabilitation 

14 agency, or by others under arrangements with 

15 such clinic or agency, unless such clinic or reha16 bilitation agency meets the requirements of 

17 paragraph (5); and 

18 ‘‘(II) if furnished by a public health agen19 cy, unless such agency meets such other condi20 tions relating to the safety of individuals who 

21 are furnished services by such agency on an 

22 outpatient basis, as the Secretary may find nec23 essary. 

24 ‘‘(C) Such term also includes speech-language pathol25 ogy services that meet the requirements of the preceding 
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1 sentence except that they are furnished to an inpatient 

2 of a hospital or extended care facility. Nothing in this sub3 section shall be construed as requiring, with respect to 

4 outpatients who are not entitled to benefits under this 

5 title, a speech-language pathologist to provide outpatient 

6 speech-language pathology services only to outpatients 

7 who are under the care of a physician or pursuant to a 

8 plan of care established by a physician. The Secretary may 

9 waive the requirement of a surety bond under paragraph 

10 (5)(E) in the case of a clinic or agency that provides a 

11 comparable surety bond under State law. 

12 ‘‘(5) A clinic or rehabilitation agency meets the re13 quirements of this paragraph if it— 

14 ‘‘(A) provides an adequate program of speech15 language pathology services for outpatients and has 

16 the facilities and personnel required for such pro17 gram or required for the supervision of such a pro18 gram, in accordance with such requirements as the 

19 Secretary may specify; 

20 ‘‘(B) has policies, established by a group of pro21 fessional personnel, including one or more speech22 language pathologists, to govern the services (re23 ferred to in subparagraph (A)) it provides; 

24 ‘‘(C) maintains clinical records on all patients; 
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1 ‘‘(D) in the case of a clinic or agency that is 

2 situated in a State in which State or applicable local 

3 law provides for the licensing of institutions of this 

4 nature— 

5 ‘‘(i) is licensed pursuant to such law, or 

6 ‘‘(ii) is approved by the agency of such 

7 State or locality responsible for licensing insti8 tutions of this nature, as meeting the standards 

9 established for such licensing; and 

10 ‘‘(E) meets such other conditions relating to the 

11 health and safety of individuals who are furnished 

12 services by such clinic or agency on an outpatient 

13 basis, as the Secretary may find necessary, and pro14 vides the Secretary on a continuing basis with a sur15 ety bond that is not less than $50,000.’’. 

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

17 this section shall apply to items and services furnished on 

18 or after January 1, 2006. 

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