II 

114TH CONGRESS 

2D SESSION S. 3435 

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 

SEPTEMBER 28, 2016 

Mr. ROBERTS (for himself, Mr. FRANKEN, Mr. BARRASSO, and Ms. 

HEITKAMP) 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 2016’’. 

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. Reinstatement and expansion of the Medicare hold harmless provision 

under the prospective payment system for hospital outpatient 

department (HOPD) services for certain hospitals. 

Sec. 5. Extension and temporary improvements to the Medicare inpatient hospital payment adjustment for low-volume hospitals. 

Sec. 6. Extension of the Medicare-dependent hospital (MDH) program. 

Sec. 7. Reinstatement of Medicare wage index reclassifications for certain hospitals. 

Sec. 8. Extension of Medicare reasonable costs payments for certain clinical diagnostic laboratory tests furnished to hospital patients in certain rural areas. 

Sec. 9. Elimination of isolation test for cost-based ambulance reimbursement 

for critical access hospitals. 

Sec. 10. Capital infrastructure revolving loan program. 

Sec. 11. Extension of Medicare incentive payment program for physician scarcity areas. 

Sec. 12. Extension of floor on Medicare work geographic adjustment. 

Sec. 13. Recognition of attending physician assistants as attending physicians 

to serve hospice patients. 

Sec. 14. Improving care planning for Medicare home health services. 

Sec. 15. Rural health clinic improvements. 

Sec. 16. Temporary Medicare payment increase for home health services furnished in a rural area. 

Sec. 17. Extension of increased Medicare payments for rural ground ambulance 

services. 

Sec. 18. Coverage of marriage and family therapist services and mental health 

counselor services under Part B of the Medicare program. 

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 2017. 

Sec. 27. Medicare payment for certain rural health clinic and Federally qualified health center services furnished to hospice patients. 

1 SEC. 2. SENSE OF THE SENATE. 

2 It is the sense of the Senate that— 


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1 (1) residents of rural and frontier communities 

2 should have access to affordable, quality health care; 

3 (2) rural and frontier communities face unique 

4 challenges in health care delivery and financing; 

5 (3) Federal health policy must reflect the 

6 unique needs of residents of rural and frontier com7 munities and such communities in an equitable and 

8 sustainable manner; and 

9 (4) stakeholders should work collectively to 

10 identify innovative policies that address the avail11 ability, delivery, and affordability of health care 

12 services in rural and frontier communities. 

13 SEC. 3. FAIRNESS IN THE MEDICARE DISPROPORTIONATE 

14 SHARE HOSPITAL (DSH) ADJUSTMENT FOR 

15 RURAL HOSPITALS. 

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

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

18 adding at the end the following new sentence: ‘‘The pre19 ceding sentence shall not apply to any hospital with re20 spect to discharges occurring on or after October 1, 2016, 

21 and before October 1, 2017.’’. 


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1 SEC. 4. REINSTATEMENT AND EXPANSION OF THE MEDI2 CARE HOLD HARMLESS PROVISION UNDER 

3 THE PROSPECTIVE PAYMENT SYSTEM FOR 

4 HOSPITAL OUTPATIENT DEPARTMENT 

5 (HOPD) 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 January 

11 1, 2016, and before January 1, 2017,’’ after 

12 ‘‘covered OPD services furnished on or after 

13 January 1, 2006, and before January 1, 

14 2013,’’; and 

15 (B) in the second sentence— 

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

17 ‘‘85’’; and 

18 (ii) by inserting the following before 

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

20 with respect to such services furnished on 

21 or after January 1, 2016, and before Jan22 uary 1, 2017’’; and 

23 (2) in subclause (III)— 

24 (A) in the first sentence— 

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

26 furnished on or after January 1, 2016, and 


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1 before January 1, 2017,’’ after ‘‘covered 

2 OPD services furnished on or after Janu3 ary 1, 2009, and before January 1, 

4 2013,’’; and 

5 (ii) by striking ‘‘85 percent’’ and in6 serting ‘‘the applicable percentage (as de7 termined under the second sentence of sub8 clause (II) for the year)’’; and 

9 (B) in the second sentence, by inserting 

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

11 or after January 1, 2016, and before January 

12 1, 2017,’’ after ‘‘covered OPD services fur13 nished on or after January 1, 2010, and before 

14 March 1, 2012,’’. 

15 SEC. 5. EXTENSION AND TEMPORARY IMPROVEMENTS TO 

16 THE MEDICARE INPATIENT HOSPITAL PAY17 MENT ADJUSTMENT FOR LOW-VOLUME HOS18 PITALS. 

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

20 U.S.C. 1395ww(d)(12)) is amended— 

21 (1) in subparagraph (B), in the matter pre22 ceding clause (i), by striking ‘‘fiscal year 2018’’ and 

23 inserting ‘‘fiscal year 2019’’; 

24 (2) in subparagraph (C)(i), by striking ‘‘fiscal 

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1 viduals entitled to, or enrolled for, benefits under 

2 part A’’ and inserting ‘‘fiscal years 2011 through 

3 2016, 1,600 discharges of individuals entitled to, or 

4 enrolled for, benefits under part A, or, with respect 

5 to fiscal years 2017 and 2018, 2,000 discharges of 

6 such individuals’’; and 

7 (3) in subparagraph (D)— 

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

9 applicable number of’’; and 

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

11 sentence: ‘‘For purposes of the preceding sen12 tence, the term ‘applicable number of dis13 charges’ means 1,600 discharges with respect to 

14 discharges occurring in fiscal years 2011 

15 through 2016, and 2,000 discharges with re16 spect to discharges occurring in fiscal years 

17 2017 and 2018.’’. 

18 SEC. 6. EXTENSION OF THE MEDICARE-DEPENDENT HOS19 PITAL (MDH) PROGRAM. 

20 (a) IN GENERAL.—Section 1886(d)(5)(G) of the So21 cial Security Act (42 U.S.C. 1395ww(d)(5)(G)) is amend22 ed— 

23 (1) in clause (i), by striking ‘‘October 1, 2017’’ 

24 and inserting ‘‘October 1, 2018’’; and 


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1 (2) in clause (ii)(II), by striking ‘‘October 1, 

2 2017’’ and inserting ‘‘October 1, 2018’’. 

3 (b) CONFORMING AMENDMENTS.— 

4 (1) EXTENSION OF TARGET AMOUNT.—Section 

5 1886(b)(3)(D) of the Social Security Act (42 U.S.C. 

6 1395ww(b)(3)(D)) is amended— 

7 (A) in the matter preceding clause (i), by 

8 striking ‘‘October 1, 2017’’ and inserting ‘‘Oc9 tober 1, 2018’’; and 

10 (B) in clause (iv), by striking ‘‘through fis11 cal year 2017’’ and inserting ‘‘through fiscal 

12 year 2018’’. 

13 (2) PERMITTING HOSPITALS TO DECLINE RE14 CLASSIFICATION.—Section 13501(e)(2) of the Omni15 bus Budget Reconciliation Act of 1993 (42 U.S.C. 

16 1395ww note) is amended by striking ‘‘through fis17 cal year 2017’’ and inserting ‘‘through fiscal year 

18 2018’’. 

19 SEC. 7. REINSTATEMENT OF MEDICARE WAGE INDEX RE20 CLASSIFICATIONS FOR CERTAIN HOSPITALS. 

21 (a) REINSTATEMENT OF CORRECTION OF MID-YEAR

22 RECLASSIFICATION EXPIRATION FOR CERTAIN HOS23 PITALS.— 

24 (1) IN GENERAL.—The first sentence of sub25 section (a) of section 106 of division B of the Tax 


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

2 1395ww note), as amended by section 117 of the 

3 Medicare, Medicaid, and SCHIP Extension Act of 

4 2007 (Public Law 110–173), section 124 of the 

5 Medicare Improvements for Patients and Providers 

6 Act of 2008 (Public Law 110–275), sections 

7 3137(a) and 10317 of the Patient Protection and 

8 Affordable Care Act (Public Law 111–148), section 

9 102 of the Medicare and Medicaid Extenders Act of 

10 2010 (Public Law 111–309), section 302(a) of the 

11 Temporary Payroll Tax Cut Continuation Act of 

12 2011 (Public Law 112–78), and section 3001(a) of 

13 the Middle Class Tax Relief and Job Creation Act 

14 of 2012 (Public Law 112–96), is amended by insert15 ing ‘‘and, in the case of a hospital described in sec16 tion 7(a)(2) of the Craig Thomas Rural Hospital 

17 and Provider Equity Act of 2016, shall apply such 

18 reclassification of such hospital during the period be19 ginning on January 1, 2016, and ending on Decem20 ber 31, 2016’’ before the period at the end. 

21 (2) HOSPITAL DESCRIBED.—A hospital de22 scribed in this paragraph is— 

23 (A) a hospital— 

24 (i) that is described in such subsection 

25 (a) such section 106; and 


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

2 and 

3 (II) for which the Secretary has deter4 mined the reinstatement under the provi5 sions of, and amendments made by, this 

6 section is appropriate; or 

7 (B) a sole community hospital located in a 

8 State with less than 10 people per square mile 

9 that was provided with a special exception re10 classification extension under section 117(a)(2) 

11 of the Medicare, Medicaid, and SCHIP Exten12 sion Act of 2007. 

13 (b) NOT BUDGET NEUTRAL.—The provisions of, and 

14 amendments made by, this section shall not be effected 

15 in a budget-neutral manner. 

16 SEC. 8. EXTENSION OF MEDICARE REASONABLE COSTS 

17 PAYMENTS FOR CERTAIN CLINICAL DIAG18 NOSTIC LABORATORY TESTS FURNISHED TO 

19 HOSPITAL PATIENTS IN CERTAIN RURAL 

20 AREAS. 

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

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

23 1395l), as amended by section 105 of division B of the 

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

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


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

2 3122 of the Patient Protection and Affordable Care Act 

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

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

5 309), is amended— 

6 (1) by striking ‘‘or during the 2-year’’ and in7 serting ‘‘, during the 2-year’’; and 

8 (2) by inserting ‘‘, or during the 1-year period 

9 beginning on January 1, 2017’’ before the period at 

10 the end. 

11 SEC. 9. ELIMINATION OF ISOLATION TEST FOR COST-BASED 

12 AMBULANCE REIMBURSEMENT FOR CRIT13 ICAL ACCESS HOSPITALS. 

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

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

16 (1) in subparagraph (B)— 

17 (A) by striking ‘‘owned and’’; and 

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

19 services are provided by the entity under an ar20 rangement with the hospital)’’ after ‘‘hospital’’; 

21 and 

22 (2) by striking the comma at the end of sub23 paragraph (B) and all that follows and inserting a 

24 period. 


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

2 this section shall apply to services furnished on or after 

3 January 1, 2017. 

4 SEC. 10. CAPITAL INFRASTRUCTURE REVOLVING LOAN 

5 PROGRAM. 

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

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

8 by adding at the end the following new section: 

9 ‘‘CAPITAL INFRASTRUCTURE REVOLVING LOAN PROGRAM

10 ‘‘SEC. 1603. (a) AUTHORITY TO MAKE AND GUAR11 ANTEE LOANS.— 

12 ‘‘(1) AUTHORITY TO MAKE LOANS.—The Sec13 retary may make loans from the fund established 

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

15 projects for capital improvements, including— 

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

17 the capital improvements; 

18 ‘‘(B) the renovation or modernization of 

19 any building; 

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

21 major movable equipment; and 

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

23 Secretary determines appropriate. 

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

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

26 guarantee the payment of principal and interest 


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1 for loans made to rural entities for projects for 

2 any capital improvement described in paragraph 

3 (1) to any non-Federal lender. 

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

5 of a guarantee of any loan made to a rural enti6 ty under subparagraph (A), the Secretary may 

7 pay to the holder of such loan, for and on be8 half of the project for which the loan was made, 

9 amounts sufficient to reduce (by not more than 

10 3 percent) the net effective interest rate other11 wise payable on such loan. 

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

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

14 for a project for capital improvement may not exceed 

15 $5,000,000. 

16 ‘‘(c) FUNDING LIMITATIONS.— 

17 ‘‘(1) GOVERNMENT CREDIT SUBSIDY EXPO18 SURE.—The total of the Government credit subsidy 

19 exposure under the Federal Credit Reform Act of 

20 1990 scoring protocol with respect to the loans out21 standing at any time with respect to which guaran22 tees have been issued, or which have been directly 

23 made, under subsection (a) may not exceed 

24 $50,000,000 per year. 


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

2 (1), the total of the principal amount of all loans di3 rectly made or guaranteed under subsection (a) may 

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

5 ‘‘(d) CAPITAL ASSESSMENT AND PLANNING

6 GRANTS.— 

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

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

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

10 for purposes of capital assessment and business 

11 planning. 

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

13 grants awarded under this subsection may not ex14 ceed $2,500,000 per year. 

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

16 may not directly make or guarantee any loan under sub17 section (a) or make a grant under subsection (d) after 

18 January 1, 2017.’’. 

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

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

21 by adding at the end the following new paragraph: 

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

23 ‘‘(i) a rural health clinic, as defined in sec24 tion 1861(aa)(2) of the Social Security Act; 


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

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

3 in— 

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

5 metropolitan statistical area; or 

6 ‘‘(II) a rural census tract of a metro7 politan statistical area (as determined 

8 under the most recent modification of the 

9 Goldsmith Modification, originally pub10 lished in the Federal Register on February 

11 27, 1992 (57 Fed. Reg. 6725)); 

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

13 rural, regional, or national referral center under 

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

15 Act; and 

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

17 hospital (as defined in section 

18 1886(d)(5)(D)(iii) of the Social Security Act). 

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

20 fact that a clinic, facility, or hospital has been geo21 graphically reclassified under the Medicare program 

22 under title XVIII of the Social Security Act shall not 

23 preclude a hospital from being considered a rural en24 tity under clause (i) or (ii) of subparagraph (A).’’. 


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1 (c) CONFORMING AMENDMENTS.—Section 1602 of 

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

3 amended— 

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

5 1603(a)(2)(B)’’ after ‘‘1601(a)(2)(B)’’; and 

6 (2) in subsection (d)— 

7 (A) in paragraph (1)(C), by striking ‘‘sec8 tion 1601(a)(2)(B)’’ and inserting ‘‘sections 

9 1601(a)(2)(B) and 1603(a)(2)(B)’’; and 

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

11 1603(a)(2)(B)’’ after ‘‘1601(a)(2)(B)’’. 

12 SEC. 11. EXTENSION OF MEDICARE INCENTIVE PAYMENT 

13 PROGRAM FOR PHYSICIAN SCARCITY AREAS. 

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

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

16 services furnished on or after April 1, 2016, and before 

17 April 1, 2017’’ after ‘‘2008’’. 

18 SEC. 12. EXTENSION OF FLOOR ON MEDICARE WORK GEO19 GRAPHIC ADJUSTMENT. 

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

21 U.S.C. 1395w–4(e)(1)(E)) is amended by striking ‘‘Janu22 ary 1, 2018’’ and inserting ‘‘January 1, 2019’’. 


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1 SEC. 13. RECOGNITION OF ATTENDING PHYSICIAN ASSIST2 ANTS AS ATTENDING PHYSICIANS TO SERVE 

3 HOSPICE PATIENTS. 

4 (a) IN GENERAL.—Section 1861(dd)(3)(B) of the So5 cial Security Act (42 U.S.C. 1395x(dd)(3)(B)) is amend6 ed— 

7 (1) by striking ‘‘or nurse practitioner’’ and in8 serting ‘‘, the nurse practitioner’’; and 

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

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

11 (aa)(5))’’. 

12 (b) PERMITTING PHYSICIAN ASSISTANTS WHEN

13 DELEGATED BY A PHYSICIAN TO ORDER HOSPICE

14 CARE.—Section 1814(a)(7)(A) of the Social Security Act 

15 (42 U.S.C. 1395f(a)(7)(A)) is amended— 

16 (1) in clause (i)(I), by striking ‘‘does not in17 clude a nurse practitioner’’ and inserting ‘‘only in18 cludes a physician assistant if a physician has dele19 gated the authority to make the certification re20 quired under this paragraph to such physician as21 sistant’’; and 

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

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

24 period— 

25 ‘‘(I) the medical director or phy26 sician described in clause (i)(II); 


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1 ‘‘(II) a physician employed by the 

2 hospice program providing (or arrang3 ing for) the care or providing care to 

4 the individual under arrangement with 

5 such hospice program; 

6 ‘‘(III) a nurse practitioner em7 ployed by such hospice program or 

8 providing care to the individual under 

9 arrangement with such hospice pro10 gram; or 

11 ‘‘(IV) a physician assistant em12 ployed by such hospice program or 

13 providing care to the individual under 

14 arrangement with such hospice pro15 gram, provided that an individual de16 scribed in subclause (I) or (II) has 

17 delegated the authority to make the 

18 recertification required under this 

19 clause to such physician assistant, 

20 recertifies at the beginning of the period 

21 that the individual is terminally ill based 

22 on such clinical judgment;’’. 

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

24 this section shall apply to items and services furnished on 

25 or after January 1, 2017. 


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1 SEC. 14. IMPROVING CARE PLANNING FOR MEDICARE 

2 HOME HEALTH SERVICES. 

3 (a) PART A PROVISIONS.—Section 1814(a) of the So4 cial Security Act (42 U.S.C. 1395f(a)) is amended— 

5 (1) in paragraph (2)— 

6 (A) in the matter preceding subparagraph 

7 (A), by inserting ‘‘, a nurse practitioner or clin8 ical nurse specialist who is working in collabo9 ration with a physician in accordance with 

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

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

12 or a physician assistant (as defined in section 

13 1861(aa)(5)) under the supervision of a physi14 cian’’ after ‘‘1866(j)’’; and 

15 (B) in subparagraph (C)— 

16 (i) by inserting ‘‘, a nurse practi17 tioner, a clinical nurse specialist, a cer18 tified nurse-midwife, or a physician assist19 ant (as the case may be)’’ after ‘‘physi20 cian’’ the first 2 times it appears; and 

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

22 a certification made by a physician’’ and 

23 all that follows through ‘‘face-to-face en24 counter’’ and inserting ‘‘, and, in the case 

25 of a certification made by a physician after 

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1 tioner, clinical nurse specialist, certified 

2 nurse-midwife, or physician assistant (as 

3 the case may be) after January 1, 2017, 

4 prior to making such certification the phy5 sician, nurse practitioner, clinical nurse 

6 specialist, certified nurse-midwife, or physi7 cian assistant must document that the 

8 physician, nurse practitioner, clinical nurse 

9 specialist, certified nurse-midwife, or physi10 cian assistant has had a face-to-face en11 counter’’; and 

12 (2) in the flush matter following paragraph 

13 (8)— 

14 (A) in the first sentence, by inserting ‘‘cer15 tified nurse-midwife,’’ after ‘‘clinical nurse spe16 cialist,’’; 

17 (B) in the second sentence— 

18 (i) by striking ‘‘physician certifi19 cation’’ and inserting ‘‘certification’’; 

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

21 2017, in the case of regulations to imple22 ment the amendments made by section 14 

23 of the Craig Thomas Rural Hospital and 

24 Provider Equity Act of 2016)’’ after 

25 ‘‘1981’’; and 


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

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

4 nurse-midwife, or physician assistant 

5 who’’; and 

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

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

9 after ‘‘physician’’. 

10 (b) PART B PROVISIONS.—Section 1835(a) of the So11 cial Security Act (42 U.S.C. 1395n(a)) is amended— 

12 (1) in paragraph (2)— 

13 (A) in the matter preceding subparagraph 

14 (A), by inserting ‘‘, a nurse practitioner or clin15 ical nurse specialist (as those terms are defined 

16 in section 1861(aa)(5)) who is working in col17 laboration with a physician in accordance with 

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

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

20 or a physician assistant (as defined in section 

21 1861(aa)(5)) under the supervision of a physi22 cian’’ after ‘‘1866(j)’’; and 

23 (B) in subparagraph (A)— 

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

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


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1 practitioner, a clinical nurse specialist, a 

2 certified nurse-midwife, or a physician as3 sistant (as the case may be)’’ after ‘‘physi4 cian’’; and 

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

6 January 1, 2010’’ and all that follows 

7 through ‘‘face-to-face encounter’’ and in8 serting ‘‘made by a physician after Janu9 ary 1, 2010, or by a nurse practitioner, 

10 clinical nurse specialist, certified nurse11 midwife, or physician assistant (as the case 

12 may be) after January 1, 2017, prior to 

13 making such certification the physician, 

14 nurse practitioner, clinical nurse specialist, 

15 certified nurse-midwife, or physician assist16 ant must document that the physician, 

17 nurse practitioner, clinical nurse specialist, 

18 certified nurse-midwife, or physician assist19 ant has had a face-to-face encounter’’; 

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

21 practitioner, clinical nurse specialist, certified nurse22 midwife, or physician assistant (as the case may 

23 be)’’ after ‘‘physician’’; 

24 (3) in the fourth sentence— 


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

2 and inserting ‘‘certification’’; 

3 (B) by inserting ‘‘(or on January 1, 2017, 

4 in the case of regulations to implement the 

5 amendments made by section 14 of the Craig 

6 Thomas Rural Hospital and Provider Equity 

7 Act of 2016)’’ after ‘‘1981’’; and 

8 (C) by striking ‘‘a physician who’’ and in9 serting ‘‘a physician, nurse practitioner, clinical 

10 nurse specialist, certified nurse-midwife, or phy11 sician assistant who’’; and 

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

13 practitioner, clinical nurse specialist, certified nurse14 midwife, or physician assistant’’ after ‘‘physician’’. 

15 (c) DEFINITION PROVISIONS.— 

16 (1) HOME HEALTH SERVICES.—Section 

17 1861(m) of the Social Security Act (42 U.S.C. 

18 1395x(m)) is amended— 

19 (A) in the matter preceding paragraph 

20 (1)— 

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

22 or a clinical nurse specialist (as those 

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

24 certified nurse-midwife (as defined in sec25 tion 1861(gg)), or a physician assistant (as 


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1 defined in subsection (aa)(5))’’ after ‘‘phy2 sician’’ the first place it appears; and 

3 (ii) by inserting ‘‘, a nurse practi4 tioner, a clinical nurse specialist, a cer5 tified nurse-midwife, or a physician assist6 ant’’ after ‘‘physician’’ the second place it 

7 appears; and 

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

9 nurse practitioner, a clinical nurse specialist, a 

10 certified nurse-midwife, or a physician assist11 ant’’ after ‘‘physician’’. 

12 (2) HOME HEALTH AGENCY.—Section 

13 1861(o)(2) of the Social Security Act (42 U.S.C. 

14 1395x(o)(2)) is amended— 

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

16 clinical nurse specialists (as those terms are de17 fined in subsection (aa)(5)), certified nurse-mid18 wives (as defined in section 1861(gg)), or physi19 cian assistants (as defined in subsection 

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

21 (B) by inserting ‘‘, nurse practitioner, clin22 ical nurse specialist, certified nurse-midwife, 

23 physician assistant,’’ after ‘‘physician’’. 


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1 (d) HOME HEALTH PROSPECTIVE PAYMENT SYSTEM

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

3 U.S.C. 1395fff) is amended— 

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

5 nurse practitioner or clinical nurse specialist (as 

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

7 certified nurse-midwife (as defined in section 

8 1861(gg)), or the physician assistant (as defined in 

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

10 (2) in subsection (e)— 

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

12 nurse practitioner or clinical nurse specialist (as 

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

14 a certified nurse-midwife (as defined in section 

15 1861(gg)), or a physician assistant (as defined 

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

17 (B) in paragraph (2)— 

18 (i) in the heading, by striking ‘‘PHY19 SICIAN CERTIFICATION’’ and inserting 

20 ‘‘RULE OF CONSTRUCTION REGARDING RE21 QUIREMENT FOR CERTIFICATION’’; and 

22 (ii) by striking ‘‘physician’’. 

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

24 this section shall apply to items and services furnished on 

25 or after January 1, 2017. 


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1 SEC. 15. RURAL HEALTH CLINIC IMPROVEMENTS. 

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

3 1395l(f)) is amended— 

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

5 end and inserting a semicolon; 

6 (2) in paragraph (2)— 

7 (A) by inserting ‘‘(before 2017)’’ after ‘‘in 

8 a subsequent year’’; and 

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

10 inserting a semicolon; and 

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

12 paragraphs: 

13 ‘‘(3) in 2017, at $110 per visit; and 

14 ‘‘(4) for years following 2017, at the limit es15 tablished under this subsection for the previous year 

16 increased by the percentage increase in the MEI (as 

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

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

19 SEC. 16. TEMPORARY MEDICARE PAYMENT INCREASE FOR 

20 HOME HEALTH SERVICES FURNISHED IN A 

21 RURAL AREA. 

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

23 Improvement, and Modernization Act of 2003 (Public Law 

24 108–173; 117 Stat. 2283), as amended by section 5201(b) 

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

26 171; 120 Stat. 46), section 3131(c) of the Patient ProtecVerDate Sep 11 2014 03:12 Oct 04, 2016 Jkt 069200 PO 00000 Frm 00025 Fmt 6652 Sfmt 6201 E:\BILLS\S3435.IS S3435

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1 tion and Affordable Care Act (Public Law 111–148; 124 

2 Stat. 428), and section 210 of the Medicare Access and 

3 CHIP Reauthorization Act of 2015 (Public Law 114–10; 

4 129 Stat. 151), is amended by striking ‘‘January 1, 2018’’ 

5 and inserting ‘‘January 1, 2019’’ each place it appears. 

6 SEC. 17. EXTENSION OF INCREASED MEDICARE PAYMENTS 

7 FOR RURAL GROUND AMBULANCE SERVICES. 

8 (a) IN GENERAL.—Section 1834(l)(13)(A) of the So9 cial Security Act (42 U.S.C. 1395m(l)(13)(A)) is amend10 ed— 

11 (1) in the matter preceding clause (i), by strik12 ing ‘‘July 1, 2004’’ and all that follows through 

13 ‘‘originates in’’; 

14 (2) in clause (i)— 

15 (A) by inserting ‘‘July 1, 2004, and before 

16 January 1, 2007, and for such services fur17 nished on or after July 1, 2008, and before 

18 January 1, 2019, for which the transportation 

19 originates in’’ before ‘‘a rural’’; and 

20 (B) by striking ‘‘2018’’ and inserting 

21 ‘‘2017, or 5 percent if such service is furnished 

22 on or after January 1, 2017, and before Janu23 ary 1, 2019’’; and 

24 (3) in clause (ii), by inserting ‘‘July 1, 2004, 

25 and before January 1, 2007, and for such services 


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1 furnished on or after July 1, 2008, and before Janu2 ary 1, 2018, for which the transportation originates 

3 in’’ before ‘‘an area not’’. 

4 (b) SUPER RURAL AMBULANCE.—Section 

5 1834(l)(12)(A) of the Social Security Act (42 U.S.C. 

6 1395m(l)(12)(A)) is amended by striking ‘‘January 1, 

7 2018’’ and inserting ‘‘January 1, 2019’’. 

8 SEC. 18. COVERAGE OF MARRIAGE AND FAMILY THERAPIST 

9 SERVICES AND MENTAL HEALTH COUNSELOR 

10 SERVICES UNDER PART B OF THE MEDICARE 

11 PROGRAM. 

12 (a) COVERAGE OF SERVICES.— 

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

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

15 amended— 

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

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

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

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

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

21 subparagraph: 

22 ‘‘(GG) marriage and family therapist services 

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

24 counselor services (as defined in subsection 

25 (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 (AA)’’ and inserting 

21 ‘‘(AA)’’; and 

22 (B) by inserting before the semicolon at 

23 the end the following: ‘‘, and (BB) 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, 2017. 

4 SEC. 19. FACILITATING THE PROVISION OF TELEHEALTH 

5 SERVICES ACROSS STATE LINES. 

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

7 provision of telehealth services, for which payment is made 

8 under the Medicare program, across State lines, the Sec9 retary of Health and Human Services shall, in consulta10 tion with representatives of States, physicians, health care 

11 practitioners, and patient advocates, encourage and facili12 tate the adoption of provisions allowing for multistate 

13 practitioner practice across State lines. 

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

15 (1) TELEHEALTH SERVICE.—The term ‘‘tele16 health service’’ has the meaning given that term in 

17 subparagraph (F) of section 1834(m)(4) of the So18 cial Security Act (42 U.S.C. 1395m(m)(4)). 

19 (2) PHYSICIAN, PRACTITIONER.—The terms 

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

21 given those terms in subparagraphs (D) and (E), re22 spectively, of such section. 

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

24 program’’ means the program of health insurance 

25 administered by the Secretary of Health and Human 


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1 Services under title XVIII of the Social Security Act 

2 (42 U.S.C. 1395 et seq.). 

3 SEC. 20. MEDICARE PART A PAYMENT FOR ANESTHESIOL4 OGIST SERVICES IN CERTAIN RURAL HOS5 PITALS BASED ON CRNA PASS-THROUGH 

6 RULES. 

7 (a) IN GENERAL.—Section 1814 of the Social Secu8 rity Act (42 U.S.C. 1395f) is amended by adding at the 

9 end the following new subsection: 

10 ‘‘Anesthesiologist Services Provided in Certain Rural 

11 Hospitals 

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

13 title, coverage and payment shall be provided under this 

14 part for physicians’ services that are anesthesia services 

15 furnished by a physician who is an anesthesiologist in a 

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

17 manner as payment is made under the exception provided 

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

19 Act of 1986, as amended by section 6132 of the Omnibus 

20 Budget Reconciliation Act of 1989 (42 U.S.C. 1395k 

21 note) (relating to payment on a reasonable cost, pass22 through basis), for certified registered nurse anesthetist 

23 services furnished by a certified registered nurse anes24 thetist in a hospital described in such section. 


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1 ‘‘(2) No payment shall be made under any other pro2 vision of this title for physicians’ services for which pay3 ment is made under this subsection. 

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

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

6 Budget Reconciliation Act of 1986, as so amended (42 

7 U.S.C. 1395k note), except that— 

8 ‘‘(A) any reference in such section to a ‘cer9 tified registered nurse anesthetist’ or ‘anesthetist’ is 

10 deemed a reference to a ‘physician who is an anes11 thesiologist’ or ‘anesthesiologist’, respectively; and 

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

13 ‘1987’ is deemed a reference to such date and year 

14 as the Secretary shall specify.’’. 

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

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

17 reporting periods beginning on or after the date of the 

18 enactment of this Act. 


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1 SEC. 21. TEMPORARY FLOOR ON THE PRACTICE EXPENSE 

2 GEOGRAPHIC INDEX FOR SERVICES FUR3 NISHED IN RURAL AREAS OUTSIDE OF FRON4 TIER STATES UNDER THE MEDICARE PHYSI5 CIAN FEE SCHEDULE. 

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

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

8 the following new subparagraph: 

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

10 GEOGRAPHIC INDEX FOR SERVICES FURNISHED

11 IN RURAL AREAS OUTSIDE OF FRONTIER

12 STATES.—For purposes of payment for services 

13 furnished in a rural area (other than a rural 

14 area located in a State to which subparagraph 

15 (I) applies) on or after January 1, 2017, and 

16 before January 1, 2018, after calculating the 

17 practice expense index under subparagraph 

18 (A)(i), the Secretary shall increase any such 

19 index to 1.0 if such index would otherwise be 

20 less than 1.0. The preceding sentence shall not 

21 be applied in a budget neutral manner.’’. 

22 SEC. 22. REVISIONS TO STANDARD FOR DESIGNATION OF 

23 SOLE COMMUNITY HOSPITALS. 

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

25 (42 U.S.C. 1395ww(d)(5)(D)(iv)) is amended by adding 

26 at the end the following new sentence: ‘‘Under such standVerDate Sep 11 2014 03:12 Oct 04, 2016 Jkt 069200 PO 00000 Frm 00036 Fmt 6652 Sfmt 6201 E:\BILLS\S3435.IS S3435

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1 ard, the time required for an individual to travel to the 

2 nearest alternative source of care shall be measured over 

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

4 Government entity for use by the general public which is 

5 the most expeditious and accessible route as designated 

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

7 SEC. 23. MEDICARE TREATMENT OF STANDBY AND ON8 CALL TIME FOR CRNA SERVICES. 

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

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

11 note), as added by section 608(c)(2) of the Family Sup12 port Act of 1988 and amended by section 6132 of the Om13 nibus Budget Reconciliation Act of 1989, is amended by 

14 adding at the end the following: 

15 ‘‘(3) In determining the reasonable costs in16 curred by a hospital or critical access hospital for 

17 the services of a certified registered nurse anes18 thetist under this subsection, the Secretary shall in19 clude standby costs and on-call costs incurred by the 

20 hospital or critical access hospital, respectively, with 

21 respect to such nurse anesthetist.’’. 

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

23 subsection (a) shall apply to costs incurred in cost report24 ing periods beginning in fiscal years after fiscal year 2007 

25 and before fiscal year 2017. 


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1 SEC. 24. STATE OFFICES OF RURAL HEALTH. 

2 Section 338J of the Public Health Service Act (42 

3 U.S.C. 254r) is amended to read as follows: 

4 ‘‘SEC. 338J. GRANTS TO STATE OFFICES OF RURAL HEALTH. 

5 ‘‘(a) IN GENERAL.—The Secretary, acting through 

6 the Director of the Federal Office of Rural Health Policy 

7 (established under section 711 of the Social Security Act), 

8 shall make grants to each State Office of Rural Health 

9 for the purpose of improving health care in rural areas. 

10 ‘‘(b) REQUIREMENT OF MATCHING FUNDS.— 

11 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

12 the Secretary may not make a grant under sub13 section (a) unless the State office of rural health in14 volved agrees, with respect to the costs to be in15 curred in carrying out the purpose described in such 

16 subsection, to provide non-Federal contributions to17 ward such costs in an amount equal to $3 for each 

18 $1 of Federal funds provided in the grant. 

19 ‘‘(2) WAIVER OR REDUCTION.—The Secretary 

20 is authorized to waive or reduce the non-Federal 

21 contribution if the State office of rural health can 

22 demonstrate that requiring matching funds would 

23 limit its ability to carry out the purpose described in 

24 subsection (a). 

25 ‘‘(3) DETERMINATION OF AMOUNT OF NON26 FEDERAL CONTRIBUTION.—Non-Federal contribuVerDate Sep 11 2014 03:12 Oct 04, 2016 Jkt 069200 PO 00000 Frm 00038 Fmt 6652 Sfmt 6201 E:\BILLS\S3435.IS S3435

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1 tions required in paragraph (1) may be in cash or 

2 in kind, fairly evaluated, including plant, equipment, 

3 or services. Amounts provided by the Federal Gov4 ernment, or services assisted or subsidized to any 

5 significant extent by the Federal Government, may 

6 not be included in determining the amount of such 

7 non-Federal contributions. 

8 ‘‘(c) CERTAIN REQUIRED ACTIVITIES.—Recipients of 

9 a grant under subsection (a) shall use the grant funds for 

10 purposes of— 

11 ‘‘(1) maintaining within the State office of 

12 rural health a clearinghouse for collecting and dis13 seminating information on— 

14 ‘‘(A) rural health care issues; 

15 ‘‘(B) research findings relating to rural 

16 health care; and 

17 ‘‘(C) innovative approaches to the delivery 

18 of health care in rural areas; 

19 ‘‘(2) coordinating the activities carried out in 

20 the State that relate to rural health care, including 

21 providing coordination for the purpose of avoiding 

22 redundancy in such activities; and 

23 ‘‘(3) identifying Federal and State programs re24 garding rural health, and providing technical assistVerDate Sep 11 2014 03:12 Oct 04, 2016 Jkt 069200 PO 00000 Frm 00039 Fmt 6652 Sfmt 6201 E:\BILLS\S3435.IS S3435

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1 ance to public and nonprofit private entities regard2 ing participation in such programs. 

3 ‘‘(d) REQUIREMENT REGARDING ANNUAL BUDGET

4 FOR OFFICE.—The Secretary may not make a grant 

5 under subsection (a) unless the State involved agrees that, 

6 for any fiscal year for which the State office of rural 

7 health receives such a grant, the office operated pursuant 

8 to subsection (a) of this section will be provided with an 

9 annual budget of not less than $150,000. 

10 ‘‘(e) CERTAIN USES OF FUNDS.— 

11 ‘‘(1) RESTRICTIONS.—The Secretary may not 

12 make a grant under subsection (a) unless the State 

13 office of rural health involved agrees that the grant 

14 will not be expended— 

15 ‘‘(A) to provide health care (including pro16 viding cash payments regarding such care); 

17 ‘‘(B) to conduct activities for which Fed18 eral funds are expended— 

19 ‘‘(i) within the State to provide tech20 nical and other nonfinancial assistance 

21 under section 330A(f); 

22 ‘‘(ii) under a memorandum of agree23 ment entered into with the State office of 

24 rural health under section 330A(h); or 


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1 ‘‘(iii) under a grant under section 

2 338I; 

3 ‘‘(C) to purchase medical equipment, to 

4 purchase ambulances, aircraft, or other vehicles, 

5 or to purchase major communications equip6 ment; 

7 ‘‘(D) to purchase or improve real property; 

8 or 

9 ‘‘(E) to carry out any activity regarding a 

10 certificate of need. 

11 ‘‘(2) AUTHORITIES.—Activities for which a 

12 State office of rural health may expend a grant 

13 under subsection (a) include— 

14 ‘‘(A) paying the costs of maintaining an 

15 office of rural health for purposes of subsection 

16 (a); 

17 ‘‘(B) subject to paragraph (1)(B)(iii), pay18 ing the costs of any activity carried out with re19 spect to recruiting and retaining health profes20 sionals to serve in rural areas of the State; and 

21 ‘‘(C) providing grants and contracts to 

22 public and nonprofit private entities to carry 

23 out activities authorized in this section. 

24 ‘‘(3) LIMIT ON INDIRECT COSTS.—The Sec25 retary may impose a limit of no more than 15 perVerDate Sep 11 2014 03:12 Oct 04, 2016 Jkt 069200 PO 00000 Frm 00041 Fmt 6652 Sfmt 6201 E:\BILLS\S3435.IS S3435

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1 cent on indirect costs claimed by the recipient of the 

2 grant. 

3 ‘‘(f) REPORTS.—The Secretary may not make a 

4 grant under subsection (a) unless the State office of rural 

5 health involved agrees— 

6 ‘‘(1) to submit to the Secretary reports or per7 formance data containing such information as the 

8 Secretary may require regarding activities carried 

9 out under this section; and 

10 ‘‘(2) to submit such a report or performance 

11 data not later than than September 30 of any fiscal 

12 year for which the State office of rural health has 

13 received such a grant. 

14 ‘‘(g) REQUIREMENT OF APPLICATION.—The Sec15 retary may not make a grant under subsection (a) unless 

16 an application for the grant is submitted to the Secretary 

17 and the application is in such form, is made in such man18 ner, and contains such agreements, assurances, and infor19 mation as the Secretary determines to be necessary to 

20 carry out such subsection. 

21 ‘‘(h) NONCOMPLIANCE.—The Secretary may not 

22 make payments under subsection (a) to a State office of 

23 rural health for any fiscal year subsequent to the first fis24 cal year of such payments unless the Secretary determines 

25 that, for the immediately preceding fiscal year, the State 


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1 office of rural health has complied with each of the agree2 ments made by the State office of rural health under this 

3 section. 

4 ‘‘(i) AUTHORIZATION OF APPROPRIATIONS.— 

5 ‘‘(1) IN GENERAL.—For the purpose of making 

6 grants under subsection (a), there are authorized to 

7 be appropriated such sums as may be necessary for 

8 each of fiscal years 2017 through 2021. 

9 ‘‘(2) AVAILABILITY.—Amounts appropriated 

10 under paragraph (1) shall remain available until ex11 pended.’’. 

12 SEC. 25. REMOVING MEDICARE 96-HOUR PHYSICIAN CER13 TIFICATION REQUIREMENT FOR INPATIENT 

14 CRITICAL ACCESS HOSPITAL SERVICES. 

15 (a) IN GENERAL.—Section 1814(a) of the Social Se16 curity Act (42 U.S.C. 1395f(a)), is amended— 

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

18 end; 

19 (2) in paragraph (7), at the end of subpara20 graph (E), by striking ‘‘; and’’ and inserting a pe21 riod; and 

22 (3) by striking paragraph (8). 

23 (b) APPLICATION.—The amendments made by sub24 section (a) shall apply with respect to items and services 

25 furnished on or after January 1, 2017. 


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1 SEC. 26. EXTENSION OF ENFORCEMENT INSTRUCTION ON 

2 SUPERVISION REQUIREMENTS FOR OUT3 PATIENT THERAPEUTIC SERVICES IN CRIT4 ICAL ACCESS AND SMALL RURAL HOSPITALS 

5 THROUGH 2017. 

6 Section 1 of Public Law 113–198, as amended by sec7 tion 1 of Public Law 114–112, is amended— 

8 (1) in the section heading, by striking ‘‘AND

9 2015’’ and inserting ‘‘, 2015, 2016, AND 2017’’; and 

10 (2) by striking ‘‘and 2015’’ and inserting ‘‘, 

11 2015, 2016, and 2017’’. 

12 SEC. 27. MEDICARE PAYMENT FOR CERTAIN RURAL 

13 HEALTH CLINIC AND FEDERALLY QUALIFIED 

14 HEALTH CENTER SERVICES FURNISHED TO 

15 HOSPICE PATIENTS. 

16 (a) IN GENERAL.—Section 1812(d)(2) of the Social 

17 Security Act (42 U.S.C. 1395d(d)(2)) is amended— 

18 (1) in subparagraph (A)— 

19 (A) in the matter preceding clause (i), by 

20 striking ‘‘subparagraphs (B) and (C)’’ and in21 serting ‘‘the succeeding provisions of this para22 graph’’; 

23 (B) in clause (ii)(II), by striking the semi24 colon at the end and inserting a period; and 

25 (C) by striking the flush matter following 

26 clause (ii)(II); and 


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1 (2) by adding at the end the following new sub2 paragraph: 

3 ‘‘(E) Subparagraph (A)(ii) shall not apply to— 

4 ‘‘(i) physicians’ services furnished by the 

5 individual’s attending physician (as defined in 

6 section 1861(dd)(3)(B)), if not an employee of 

7 the hospice program; 

8 ‘‘(ii) services provided by (or under ar9 rangements made by) the hospice program; or 

10 ‘‘(iii) rural health clinic services (as de11 fined in paragraph (1) of section 1861(aa)) and 

12 Federally qualified health center services (as 

13 defined in paragraph (3) of such section) if 

14 such services— 

15 ‘‘(I) would otherwise be physicians’ 

16 services if furnished by an individual not 

17 affiliated with a rural health clinic (as de18 fined in paragraph (2) of such section) or 

19 a Federally qualified health center (as de20 fined in paragraph (4) of such section); 

21 and 

22 ‘‘(II) are— 

23 ‘‘(aa) furnished by the individ24 ual’s attending physician (as so deVerDate Sep 11 2014 03:12 Oct 04, 2016 Jkt 069200 PO 00000 Frm 00045 Fmt 6652 Sfmt 6201 E:\BILLS\S3435.IS S3435

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1 fined), if not an employee of the hos2 pice program; or 

3 ‘‘(bb) provided under arrange4 ments made by the hospice program.’’. 

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

6 this section shall apply to services furnished on or after 

7 the date that is six months after the date of the enactment 

8 of this Act. 

Æ 


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