II 

111TH CONGRESS 

1ST SESSION S. 318 

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

care under the Medicare program for beneficiaries residing in rural areas. 

IN THE SENATE OF THE UNITED STATES 

JANUARY 26, 2009 

Mr. GRASSLEY introduced the following bill; which was read twice and referred 

to the Committee on Finance 

A BILL 

To amend title XVIII of the Social Security Act to improve 

access to health care under the Medicare program for 

beneficiaries residing in rural areas. 

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 ‘‘Medicare Rural Health Access Improvement Act of 

6 2009’’. 

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

8 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—PROVISIONS RELATING TO MEDICARE PART A 


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Sec. 101. Extension of Medicare FLEX grants. 

Sec. 102. Improvements to the medicare-dependent hospital (MDH) program. 

Sec. 103. Temporary improvements to the Medicare inpatient hospital payment 

adjustment for low-volume hospitals. 

Sec. 104. Temporary elimination of the DSH adjustment cap. 

TITLE II—PROVISIONS RELATING TO MEDICARE PART B 

Sec. 201. Extension and expansion of the Medicare hold harmless provision 

under the prospective payment system for hospital outpatient 

department (HOPD) services for certain hospitals. 

Sec. 202. Treatment of rural sole community hospitals and medicare dependent, small rural hospitals under the prospective payment system for hospital outpatient department (HOPD) services. 

Sec. 203. Recognition of equality of physician work in all geographic areas 

under the Medicare physician fee schedule. 

Sec. 204. Revisions to the practice expense geographic adjustment under the 

Medicare physician fee schedule. 

Sec. 205. Extension of treatment of certain physician pathology services under 

Medicare. 

Sec. 206. Extension of increased Medicare payments for rural ground ambulance services. 

Sec. 207. Rural health clinic improvements. 

Sec. 208. Exemption for suppliers in small MSAs and rural areas. 

Sec. 209. 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 TITLE I—PROVISIONS RELATING 

2 TO MEDICARE PART A 

3 SEC. 101. EXTENSION OF MEDICARE FLEX GRANTS. 

4 Section 1820(j) of the Social Security Act (42 U.S.C. 

5 1395i–4(j)) is amended by striking ‘‘fiscal years 2009 and 

6 2010’’ each place it appears and inserting ‘‘fiscal years 

7 2009, 2010, and 2011’’. 

8 SEC. 102. IMPROVEMENTS TO THE MEDICARE-DEPENDENT 

9 HOSPITAL (MDH) PROGRAM. 

10 (a) USE OF NON-WAGE ADJUSTED PPS RATE.— 

11 Section 1886(d)(5)(G) of the Social Security Act (42 

12 U.S.C. 1395ww(d)(5)(G)) is amended by adding at the 

13 end the following new clause: 


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1 ‘‘(v) In the case of discharges occurring on or after 

2 October 1, 2009, and before October 1, 2011, in deter3 mining the amount under paragraph (1)(A)(iii) for pur4 poses of clauses (i) and (ii)(II), such amount shall, if it 

5 results in greater payments to the hospital, be determined 

6 without regard to any adjustment for different area wage 

7 levels under paragraph (3)(E).’’. 

8 (b) ENHANCED PAYMENT FOR AMOUNT BY WHICH

9 THE TARGET EXCEEDS THE PPS RATE.—Section 

10 1886(d)(5)(G)(ii)(II) of the Social Security Act (42 

11 U.S.C. 1395ww(d)(5)(G)(ii)(II)) is amended by inserting 

12 ‘‘, and before October 1, 2009, or 85 percent in the case 

13 of discharges occurring on or after October 1, 2009, and 

14 before October 1, 2011’’ after ‘‘October 1, 2006’’. 

15 SEC. 103. TEMPORARY IMPROVEMENTS TO THE MEDICARE 

16 INPATIENT HOSPITAL PAYMENT ADJUST17 MENT FOR LOW-VOLUME HOSPITALS. 

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

19 U.S.C. 1395ww(d)(12)) is amended— 

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

21 after ‘‘subparagraph (B)’’; 

22 (2) in subparagraph (B), by striking ‘‘The Sec23 retary’’ and inserting ‘‘For discharges occurring in 

24 fiscal years 2005 through 2009 and for discharges 


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1 occurring in fiscal year 2012 and subsequent fiscal 

2 years, the Secretary’’; 

3 (3) in subparagraph (C)(i)— 

4 (A) by inserting ‘‘(or, with respect to fiscal 

5 years 2010 and 2011, 15 road miles)’’ after 

6 ‘‘25 road miles’’; and 

7 (B) by inserting ‘‘(or, with respect to fiscal 

8 years 2010 and 2011, 2,000 discharges of indi9 viduals entitled to, or enrolled for, benefits 

10 under part A)’’ after ‘‘800 discharges’’; and 

11 (4) by adding at the end the following new sub12 paragraph: 

13 ‘‘(D) TEMPORARY APPLICABLE PERCENT14 AGE INCREASE.—For discharges occurring in 

15 fiscal years 2010 or 2011, the Secretary shall 

16 determine an applicable percentage increase for 

17 purposes of subparagraph (A) using a linear 

18 sliding scale ranging from 25 percent for low19 volume hospitals with fewer than an appro20 priate number (as determined by the Secretary) 

21 of discharges of individuals entitled to, or en22 rolled for, benefits under part A in the fiscal 

23 year to 0 percent for low-volume hospitals with 

24 greater than 2,000 discharges of such individ25 uals in the fiscal year.’’. 


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1 SEC. 104. TEMPORARY ELIMINATION OF THE DSH ADJUST2 MENT CAP. 

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

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

5 adding at the end the following new sentence: ‘‘The pre6 ceding sentence shall not apply to any hospital in the case 

7 of discharges occurring on or after October 1, 2009, and 

8 before October 1, 2011.’’. 

9 TITLE II—PROVISIONS RELAT10 ING TO MEDICARE PART B 

11 SEC. 201. EXTENSION AND EXPANSION OF THE MEDICARE 

12 HOLD HARMLESS PROVISION UNDER THE 

13 PROSPECTIVE PAYMENT SYSTEM FOR HOS14 PITAL OUTPATIENT DEPARTMENT (HOPD) 

15 SERVICES FOR CERTAIN HOSPITALS. 

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

17 (42 U.S.C. 1395l(t)(7)(D)(i)) is amended— 

18 (1) in subclause (II), in the second sentence— 

19 (A) by striking ‘‘and 85’’ and inserting 

20 ‘‘85’’; and 

21 (B) by inserting the following before the 

22 period at the end: ‘‘, and 100 percent with re23 spect to such services furnished in 2010’’; and 

24 (2) in subclause (III)— 

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

26 ‘‘2011’’; and 


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

2 ‘‘the applicable percentage (as determined 

3 under the second sentence of subclause (II) for 

4 the year)’’. 

5 SEC. 202. TREATMENT OF RURAL SOLE COMMUNITY HOS6 PITALS AND MEDICARE DEPENDENT, SMALL 

7 RURAL HOSPITALS UNDER THE PROSPEC8 TIVE PAYMENT SYSTEM FOR HOSPITAL OUT9 PATIENT DEPARTMENT (HOPD) SERVICES. 

10 Section 1833(t)(13) of the Social Security Act (42 

11 U.S.C. 1395l(t)(13)) is amended— 

12 (1) in the heading, by striking ‘‘AUTHORIZA13 TION OF ADJUSTMENT’’ and inserting ‘‘ADJUST14 MENT’’; 

15 (2) in subparagraph (B)— 

16 (A) in the heading, by inserting ‘‘FOR 2006

17 THROUGH 2009’’ after ‘‘ADJUSTMENT’’; and 

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

19 sentence: ‘‘Such authority shall apply with re20 spect to services furnished in 2006, 2007, 2008, 

21 or 2009.’’; and 

22 (3) by adding at the end the following new sub23 paragraph: 


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1 ‘‘(C) ADJUSTMENT FOR 2010 AND SUBSE2 QUENT YEARS FOR CERTAIN RURAL HOS3 PITALS.— 

4 ‘‘(i) ADJUSTMENT.— 

5 ‘‘(I) IN GENERAL.—Subject to 

6 clause (ii), in the case of covered OPD 

7 services furnished on or after January 

8 1, 2010, by a sole community hospital 

9 (as defined in subparagraph (D)(iii) 

10 of section 1886(d)(5)) located in a 

11 rural area or a medicare-dependent, 

12 small rural hospital (as defined in 

13 subparagraph (G)(iv) of such section, 

14 the amount of payment that would 

15 otherwise be made for such service 

16 under this subsection shall be in17 creased by an amount equal to 7.1 

18 percent of such amount. Such increase 

19 shall be applied before calculating 

20 outliers and coinsurance. 

21 ‘‘(II) REVISION WITH NOTICE

22 AND COMMENT.—In the case of cov23 ered OPD services furnished on or 

24 after January 1, 2011, the Secretary 

25 may revise the percent described in 


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1 subclause (I) through the promulga2 tion of a regulation. 

3 ‘‘(ii) NOT APPLICABLE TO PASS4 THROUGH DEVICES, DRUGS, AND

5 BIOLOGICALS.—The increase under clause 

6 (i) shall not apply to the payment for a de7 vice, drug, or biological described in clause 

8 (i), (ii), (iii), or (iv) of paragraph (6)(A). 

9 ‘‘(iii) EXEMPTION FROM BUDGET

10 NEUTRALITY.—The provisions of this sub11 paragraph shall not be effected in a budg12 et-neutral manner under this subsection.’’. 

13 SEC. 203. RECOGNITION OF EQUALITY OF PHYSICIAN WORK 

14 IN ALL GEOGRAPHIC AREAS UNDER THE 

15 MEDICARE PHYSICIAN FEE SCHEDULE. 

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

17 U.S.C. 1395w–4(e)(1)) is amended— 

18 (1) in subparagraph (A), in the matter pre19 ceding clause (i), by striking ‘‘subparagraphs (B)’’ 

20 through ‘‘the Secretary’’ and inserting ‘‘the suc21 ceeding provisions of this paragraph, the Secretary’’; 

22 and 

23 (2) by inserting after subparagraph (E) the fol24 lowing new subparagraph: 


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1 ‘‘(F) RECOGNITION OF EQUALITY OF PHY2 SICIAN WORK IN ALL GEOGRAPHIC AREAS.—In 

3 recognition of the fact that the physician work 

4 for a service is the same in all geographic areas, 

5 and should be similarly valued under this title, 

6 for services furnished on or after January 1, 

7 2010, the geographic index for physician work 

8 under subparagraph (A)(iii) shall be 1.0 in all 

9 fee schedule areas.’’. 

10 SEC. 204. REVISIONS TO THE PRACTICE EXPENSE GEO11 GRAPHIC ADJUSTMENT UNDER THE MEDI12 CARE PHYSICIAN FEE SCHEDULE. 

13 (a) ESTABLISHMENT OF FLOOR.—Section 

14 1848(e)(1) of the Social Security Act (42 U.S.C. 1395w– 

15 4(e)(1)) is amended by adding at the end the following 

16 new subparagraph: 

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

18 GEOGRAPHIC INDEX.—After calculating the 

19 practice expense geographic index in subpara20 graph (A)(i), for purposes of payment for serv21 ices furnished on or after January 1, 2010, the 

22 Secretary shall increase the practice expense ge23 ographic index to 1.0 for any locality for which 

24 such practice expense geographic index is less 

25 than 1.0.’’. 


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1 (b) MORE APPROPRIATE RECOGNITION OF PRACTICE

2 EXPENSE DIFFERENCES IN EMPLOYEE WAGES AND OF3 FICE RENTS AMONG GEOGRAPHIC AREAS.—Section 

4 1848(e)(1) of the Social Security Act (42 U.S.C. 1395w– 

5 4(e)(1)), as amended by subsection (a), is amended by 

6 adding at the end the following new subparagraph: 

7 ‘‘(I) MORE APPROPRIATE RECOGNITION OF

8 DIFFERENCES IN EMPLOYEE WAGES AND OF9 FICE RENTS AMONG AREAS.— 

10 ‘‘(i) IN GENERAL.—In recognition of 

11 the limitations on available data (as de12 scribed in clause (ii)) for use as the em13 ployee wage and office rent proxies in the 

14 practice expense geographic index de15 scribed in subparagraph (A)(i), and in 

16 order to more appropriately reflect dif17 ferences among different fee schedule 

18 areas, for services furnished on or after 

19 January 1, 2010, such practice expense ge20 ographic index shall be an index which reflects 1 21 ⁄2 of the difference between the rel22 ative costs of employee wages and rents in 

23 each of the different fee schedule areas 

24 and the national average of such employee 

25 wages and rents. 


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1 ‘‘(ii) LIMITATIONS ON AVAILABLE

2 DATA.—The limitations on available data 

3 described in this clause are the following: 

4 ‘‘(I) The need to use proxy data 

5 to reflect differences in employee 

6 wages and rents among areas. 

7 ‘‘(II) Wages for some categories 

8 of employees being determined in na9 tional markets. 

10 ‘‘(III) Physicians having to com11 pete for some employees in market 

12 areas that cross fee schedule areas. 

13 ‘‘(IV) Physicians in rural areas 

14 frequently having to locate their of15 fices close to urban areas and com16 peting with urban rent markets.’’. 

17 SEC. 205. EXTENSION OF TREATMENT OF CERTAIN PHYSI18 CIAN PATHOLOGY SERVICES UNDER MEDI19 CARE. 

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

21 SCHIP Benefits Improvement and Protection Act of 2000 

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

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

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


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

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

3 and SCHIP Extension Act of 2007 (Public Law 110–173) 

4 and section 136 of the Medicare Improvements for Pa5 tients and Providers Act of 2008 (Public Law 110–275), 

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

7 and 2010’’. 

8 SEC. 206. EXTENSION OF INCREASED MEDICARE PAYMENTS 

9 FOR RURAL GROUND AMBULANCE SERVICES. 

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

11 U.S.C. 1395m(l)(13)(A)) is amended— 

12 (1) in the matter preceding clause (i)— 

13 (A) by striking ‘‘2007, and for’’ and in14 serting ‘‘2007, for’’; and 

15 (B) by inserting ‘‘, and for such services 

16 described in clause (i) furnished on or after 

17 January 1, 2010, and before January 1, 2011’’ 

18 after ‘‘2010’’; and 

19 (2) in clause (i), by inserting ‘‘, or 5 percent if 

20 such service is furnished on or after January 1, 

21 2010, and before January 1, 2011’’ after ‘‘2010’’. 

22 SEC. 207. RURAL HEALTH CLINIC IMPROVEMENTS. 

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

24 1395l(f)) is amended— 


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

2 end and inserting a semicolon; 

3 (2) in paragraph (2)— 

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

5 a subsequent year’’; and 

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

7 inserting a semicolon; and 

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

9 paragraphs: 

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

11 ‘‘(4) in a subsequent year, at the limit estab12 lished under this subsection for the previous year in13 creased by the percentage increase in the MEI (as 

14 so defined) furnished as of the first day of that 

15 year.’’. 

16 SEC. 208. EXEMPTION FOR SUPPLIERS IN SMALL MSAS AND 

17 RURAL AREAS. 

18 (a) EXEMPTION.—Section 1847(a)(3) of the Social 

19 Security Act (42 U.S.C. 1395w–3(a)(3)) is amended— 

20 (1) in the matter preceding subparagraph (A), 

21 by striking ‘‘may’’ and inserting ‘‘shall’’; and 

22 (2) by striking subparagraph (A) and inserting 

23 the following: 


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1 ‘‘(A) rural areas and small metropolitan 

2 statistical areas with a population of 600,000 

3 or less; and’’. 

4 (b) INAPPLICABILITY OF COMPETITIVELY BID

5 PRICES TO RURAL AND SMALL MSAS.—Section 

6 1834(a)(1)(F)(ii) of the Social Security Act (42 U.S.C. 

7 1395m(a)(1)(F)(ii)) is amended by striking ‘‘the Sec8 retary’’ and inserting ‘‘except in the case of any area that 

9 is exempt from the programs under section 1847 pursuant 

10 to subsection (a)(3)(A) of such section, the Secretary’’. 

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

12 this section shall take effect as if included in the enact13 ment of section 302 of the Medicare Prescription Drug, 

14 Improvement, and Modernization Act of 2003 (Public Law 

15 108–173; 117 Stat. 2223). 

16 SEC. 209. PERMITTING PHYSICIAN ASSISTANTS TO ORDER 

17 POST-HOSPITAL EXTENDED CARE SERVICES 

18 AND TO PROVIDE FOR RECOGNITION OF AT19 TENDING PHYSICIAN ASSISTANTS AS AT20 TENDING PHYSICIANS TO SERVE HOSPICE 

21 PATIENTS. 

22 (a) ORDERING POST-HOSPITAL EXTENDED CARE

23 SERVICES.— 

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

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


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1 matter preceding subparagraph (A), is amended by 

2 striking ‘‘nurse practitioner or clinical nurse spe3 cialist’’ and inserting ‘‘nurse practitioner, a clinical 

4 nurse specialist, or a physician assistant (as those 

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

6 (2) CONFORMING AMENDMENT.—Section 

7 1814(a) of the Social Security Act (42 U.S.C. 

8 1395f(a)) is amended, in the second sentence, by 

9 striking ‘‘or clinical nurse specialist’’ and inserting 

10 ‘‘clinical nurse specialist, or physician assistant’’. 

11 (b) RECOGNITION OF ATTENDING PHYSICIAN AS12 SISTANTS AS ATTENDING PHYSICIANS TO SERVE HOS13 PICE PATIENTS.— 

14 (1) IN GENERAL.—Section 1861(dd)(3)(B) of 

15 the Social Security Act (42 U.S.C. 1395x(dd)(3)(B)) 

16 is amended— 

17 (A) by striking ‘‘or nurse’’ and inserting ‘‘, 

18 the nurse’’; and 

19 (B) by inserting ‘‘, or the physician assist20 ant (as defined in such subsection)’’ after ‘‘sub21 section (aa)(5))’’. 

22 (2) CLARIFICATION OF HOSPICE ROLE OF PHY23 SICIAN ASSISTANTS.—Section 1814(a)(7)(A)(i)(I) of 

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


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1 1395f(a)(7)(A)(i)(I)) is amended by inserting ‘‘or a 

2 physician assistant’’ after ‘‘a nurse practitioner’’. 

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

4 this section shall apply to items and services furnished on 

5 or after January 1, 2010. 

Æ 


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