```

[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[S. 3435 Introduced in Senate (IS)]

<DOC>

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.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Craig Thomas Rural 
Hospital and Provider Equity Act of 2016''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

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.

SEC. 2. SENSE OF THE SENATE.

    It is the sense of the Senate that--
            (1) residents of rural and frontier communities should have 
        access to affordable, quality health care;
            (2) rural and frontier communities face unique challenges 
        in health care delivery and financing;
            (3) Federal health policy must reflect the unique needs of 
        residents of rural and frontier communities and such 
        communities in an equitable and sustainable manner; and
            (4) stakeholders should work collectively to identify 
        innovative policies that address the availability, delivery, 
        and affordability of health care services in rural and frontier 
        communities.

SEC. 3. FAIRNESS IN THE MEDICARE DISPROPORTIONATE SHARE HOSPITAL (DSH) 
              ADJUSTMENT FOR RURAL HOSPITALS.

    Section 1886(d)(5)(F)(xiv)(II) of the Social Security Act (42 
U.S.C. 1395ww(d)(5)(F)(xiv)(II)) is amended by adding at the end the 
following new sentence: ``The preceding sentence shall not apply to any 
hospital with respect to discharges occurring on or after October 1, 
2016, and before October 1, 2017.''.

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.

    Section 1833(t)(7)(D)(i) of the Social Security Act (42 U.S.C. 
1395l(t)(7)(D)(i)) is amended--
            (1) in subclause (II)--
                    (A) in the first sentence, by inserting ``and for 
                such services furnished on or after January 1, 2016, 
                and before January 1, 2017,'' after ``covered OPD 
                services furnished on or after January 1, 2006, and 
                before January 1, 2013,''; and
                    (B) in the second sentence--
                            (i) by striking ``and 85'' and inserting 
                        ``85''; and
                            (ii) by inserting the following before the 
                        period at the end: ``, and 100 percent with 
                        respect to such services furnished on or after 
                        January 1, 2016, and before January 1, 2017''; 
                        and
            (2) in subclause (III)--
                    (A) in the first sentence--
                            (i) by inserting ``and for such services 
                        furnished on or after January 1, 2016, and 
                        before January 1, 2017,'' after ``covered OPD 
                        services furnished on or after January 1, 2009, 
                        and before January 1, 2013,''; and
                            (ii) by striking ``85 percent'' and 
                        inserting ``the applicable percentage (as 
                        determined under the second sentence of 
                        subclause (II) for the year)''; and
                    (B) in the second sentence, by inserting ``and in 
                the case of such services furnished on or after January 
                1, 2016, and before January 1, 2017,'' after ``covered 
                OPD services furnished on or after January 1, 2010, and 
                before March 1, 2012,''.

SEC. 5. EXTENSION AND TEMPORARY IMPROVEMENTS TO THE MEDICARE INPATIENT 
              HOSPITAL PAYMENT ADJUSTMENT FOR LOW-VOLUME HOSPITALS.

    Section 1886(d)(12) of the Social Security Act (42 U.S.C. 
1395ww(d)(12)) is amended--
            (1) in subparagraph (B), in the matter preceding clause 
        (i), by striking ``fiscal year 2018'' and inserting ``fiscal 
        year 2019'';
            (2) in subparagraph (C)(i), by striking ``fiscal years 2011 
        through 2017, 1,600 discharges of individuals entitled to, or 
        enrolled for, benefits under part A'' and inserting ``fiscal 
        years 2011 through 2016, 1,600 discharges of individuals 
        entitled to, or enrolled for, benefits under part A, or, with 
        respect to fiscal years 2017 and 2018, 2,000 discharges of such 
        individuals''; and
            (3) in subparagraph (D)--
                    (A) by striking ``1,600'' and inserting ``the 
                applicable number of''; and
                    (B) by adding at the end the following new 
                sentence: ``For purposes of the preceding sentence, the 
                term `applicable number of discharges' means 1,600 
                discharges with respect to discharges occurring in 
                fiscal years 2011 through 2016, and 2,000 discharges 
                with respect to discharges occurring in fiscal years 
                2017 and 2018.''.

SEC. 6. EXTENSION OF THE MEDICARE-DEPENDENT HOSPITAL (MDH) PROGRAM.

    (a) In General.--Section 1886(d)(5)(G) of the Social Security Act 
(42 U.S.C. 1395ww(d)(5)(G)) is amended--
            (1) in clause (i), by striking ``October 1, 2017'' and 
        inserting ``October 1, 2018''; and
            (2) in clause (ii)(II), by striking ``October 1, 2017'' and 
        inserting ``October 1, 2018''.
    (b) Conforming Amendments.--
            (1) Extension of target amount.--Section 1886(b)(3)(D) of 
        the Social Security Act (42 U.S.C. 1395ww(b)(3)(D)) is 
        amended--
                    (A) in the matter preceding clause (i), by striking 
                ``October 1, 2017'' and inserting ``October 1, 2018''; 
                and
                    (B) in clause (iv), by striking ``through fiscal 
                year 2017'' and inserting ``through fiscal year 2018''.
            (2) Permitting hospitals to decline reclassification.--
        Section 13501(e)(2) of the Omnibus Budget Reconciliation Act of 
        1993 (42 U.S.C. 1395ww note) is amended by striking ``through 
        fiscal year 2017'' and inserting ``through fiscal year 2018''.

SEC. 7. REINSTATEMENT OF MEDICARE WAGE INDEX RECLASSIFICATIONS FOR 
              CERTAIN HOSPITALS.

    (a) Reinstatement of Correction of Mid-Year Reclassification 
Expiration for Certain Hospitals.--
            (1) In general.--The first sentence of subsection (a) of 
        section 106 of division B of the Tax Relief and Health Care Act 
        of 2006 (42 U.S.C. 1395ww note), as amended by section 117 of 
        the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public 
        Law 110-173), section 124 of the Medicare Improvements for 
        Patients and Providers Act of 2008 (Public Law 110-275), 
        sections 3137(a) and 10317 of the Patient Protection and 
        Affordable Care Act (Public Law 111-148), section 102 of the 
        Medicare and Medicaid Extenders Act of 2010 (Public Law 111-
        309), section 302(a) of the Temporary Payroll Tax Cut 
        Continuation Act of 2011 (Public Law 112-78), and section 
        3001(a) of the Middle Class Tax Relief and Job Creation Act of 
        2012 (Public Law 112-96), is amended by inserting ``and, in the 
        case of a hospital described in section 7(a)(2) of the Craig 
        Thomas Rural Hospital and Provider Equity Act of 2016, shall 
        apply such reclassification of such hospital during the period 
        beginning on January 1, 2016, and ending on December 31, 2016'' 
        before the period at the end.
            (2) Hospital described.--A hospital described in this 
        paragraph is--
                    (A) a hospital--
                            (i) that is described in such subsection 
                        (a) such section 106; and
                            (ii)(I) that is located in a rural area; 
                        and
                            (II) for which the Secretary has determined 
                        the reinstatement under the provisions of, and 
                        amendments made by, this section is 
                        appropriate; or
                    (B) a sole community hospital located in a State 
                with less than 10 people per square mile that was 
                provided with a special exception reclassification 
                extension under section 117(a)(2) of the Medicare, 
                Medicaid, and SCHIP Extension Act of 2007.
    (b) Not Budget Neutral.--The provisions of, and amendments made by, 
this section shall not be effected in a budget-neutral manner.

SEC. 8. EXTENSION OF MEDICARE REASONABLE COSTS PAYMENTS FOR CERTAIN 
              CLINICAL DIAGNOSTIC LABORATORY TESTS FURNISHED TO 
              HOSPITAL PATIENTS IN CERTAIN RURAL AREAS.

    Section 416(b) of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (42 U.S.C. 1395l), as amended by section 105 
of division B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 
1395l note), section 107 of the Medicare, Medicaid, and SCHIP Extension 
Act of 2007 (42 U.S.C. 1395l note), section 3122 of the Patient 
Protection and Affordable Care Act (Public Law 111-148), and section 
109 of the Medicare and Medicaid Extenders Act of 2010 (Public Law 111-
309), is amended--
            (1) by striking ``or during the 2-year'' and inserting ``, 
        during the 2-year''; and
            (2) by inserting ``, or during the 1-year period beginning 
        on January 1, 2017'' before the period at the end.

SEC. 9. ELIMINATION OF ISOLATION TEST FOR COST-BASED AMBULANCE 
              REIMBURSEMENT FOR CRITICAL ACCESS HOSPITALS.

    (a) In General.--Section 1834(l)(8) of the Social Security Act (42 
U.S.C. 1395m(l)(8)) is amended--
            (1) in subparagraph (B)--
                    (A) by striking ``owned and''; and
                    (B) by inserting ``(including when such services 
                are provided by the entity under an arrangement with 
                the hospital)'' after ``hospital''; and
            (2) by striking the comma at the end of subparagraph (B) 
        and all that follows and inserting a period.
    (b) Effective Date.--The amendments made by this section shall 
apply to services furnished on or after January 1, 2017.

SEC. 10. CAPITAL INFRASTRUCTURE REVOLVING LOAN PROGRAM.

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

            ``capital infrastructure revolving loan program

    ``Sec. 1603.  (a) Authority To Make and Guarantee Loans.--
            ``(1) Authority to make loans.--The Secretary may make 
        loans from the fund established under section 1602(d) to any 
        rural entity for projects for capital improvements, including--
                    ``(A) the acquisition of land necessary for the 
                capital improvements;
                    ``(B) the renovation or modernization of any 
                building;
                    ``(C) the acquisition or repair of fixed or major 
                movable equipment; and
                    ``(D) such other project expenses as the Secretary 
                determines appropriate.
            ``(2) Authority to guarantee loans.--
                    ``(A) In general.--The Secretary may guarantee the 
                payment of principal and interest for loans made to 
                rural entities for projects for any capital improvement 
                described in paragraph (1) to any non-Federal lender.
                    ``(B) Interest subsidies.--In the case of a 
                guarantee of any loan made to a rural entity under 
                subparagraph (A), the Secretary may pay to the holder 
                of such loan, for and on behalf of the project for 
                which the loan was made, amounts sufficient to reduce 
                (by not more than 3 percent) the net effective interest 
                rate otherwise payable on such loan.
    ``(b) Amount of Loan.--The principal amount of a loan directly made 
or guaranteed under subsection (a) for a project for capital 
improvement may not exceed $5,000,000.
    ``(c) Funding Limitations.--
            ``(1) Government credit subsidy exposure.--The total of the 
        Government credit subsidy exposure under the Federal Credit 
        Reform Act of 1990 scoring protocol with respect to the loans 
        outstanding at any time with respect to which guarantees have 
        been issued, or which have been directly made, under subsection 
        (a) may not exceed $50,000,000 per year.
            ``(2) Total amounts.--Subject to paragraph (1), the total 
        of the principal amount of all loans directly made or 
        guaranteed under subsection (a) may not exceed $250,000,000 per 
        year.
    ``(d) Capital Assessment and Planning Grants.--
            ``(1) Nonrepayable grants.--Subject to paragraph (2), the 
        Secretary may make a grant to a rural entity, in an amount not 
        to exceed $50,000, for purposes of capital assessment and 
        business planning.
            ``(2) Limitation.--The cumulative total of grants awarded 
        under this subsection may not exceed $2,500,000 per year.
    ``(e) Termination of Authority.--The Secretary may not directly 
make or guarantee any loan under subsection (a) or make a grant under 
subsection (d) after January 1, 2017.''.
    (b) Rural Entity Defined.--Section 1624 of the Public Health 
Service Act (42 U.S.C. 300s-3) is amended by adding at the end the 
following new paragraph:
            ``(15)(A) The term `rural entity' includes--
                    ``(i) a rural health clinic, as defined in section 
                1861(aa)(2) of the Social Security Act;
                    ``(ii) any medical facility with at least 1 bed, 
                but with less than 50 beds, that is located in--
                            ``(I) a county that is not part of a 
                        metropolitan statistical area; or
                            ``(II) a rural census tract of a 
                        metropolitan statistical area (as determined 
                        under the most recent modification of the 
                        Goldsmith Modification, originally published in 
                        the Federal Register on February 27, 1992 (57 
                        Fed. Reg. 6725));
                    ``(iii) a hospital that is classified as a rural, 
                regional, or national referral center under section 
                1886(d)(5)(C) of the Social Security Act; and
                    ``(iv) a hospital that is a sole community hospital 
                (as defined in section 1886(d)(5)(D)(iii) of the Social 
                Security Act).
            ``(B) For purposes of subparagraph (A), the fact that a 
        clinic, facility, or hospital has been geographically 
        reclassified under the Medicare program under title XVIII of 
        the Social Security Act shall not preclude a hospital from 
        being considered a rural entity under clause (i) or (ii) of 
        subparagraph (A).''.
    (c) Conforming Amendments.--Section 1602 of the Public Health 
Service Act (42 U.S.C. 300q-2) is amended--
            (1) in subsection (b)(2)(D), by inserting ``or 
        1603(a)(2)(B)'' after ``1601(a)(2)(B)''; and
            (2) in subsection (d)--
                    (A) in paragraph (1)(C), by striking ``section 
                1601(a)(2)(B)'' and inserting ``sections 1601(a)(2)(B) 
                and 1603(a)(2)(B)''; and
                    (B) in paragraph (2)(A), by inserting ``or 
                1603(a)(2)(B)'' after ``1601(a)(2)(B)''.

SEC. 11. EXTENSION OF MEDICARE INCENTIVE PAYMENT PROGRAM FOR PHYSICIAN 
              SCARCITY AREAS.

    Section 1833(u)(1) of the Social Security Act (42 U.S.C. 
1395l(u)(1)) is amended by inserting ``, and such services furnished on 
or after April 1, 2016, and before April 1, 2017'' after ``2008''.

SEC. 12. EXTENSION OF FLOOR ON MEDICARE WORK GEOGRAPHIC ADJUSTMENT.

    Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w-
4(e)(1)(E)) is amended by striking ``January 1, 2018'' and inserting 
``January 1, 2019''.

SEC. 13. RECOGNITION OF ATTENDING PHYSICIAN ASSISTANTS AS ATTENDING 
              PHYSICIANS TO SERVE HOSPICE PATIENTS.

    (a) In General.--Section 1861(dd)(3)(B) of the Social Security Act 
(42 U.S.C. 1395x(dd)(3)(B)) is amended--
            (1) by striking ``or nurse practitioner'' and inserting ``, 
        the nurse practitioner''; and
            (2) by inserting ``, or the physician assistant (as defined 
        in such subsection)'' after ``subsection (aa)(5))''.
    (b) Permitting Physician Assistants When Delegated by a Physician 
To Order Hospice Care.--Section 1814(a)(7)(A) of the Social Security 
Act (42 U.S.C. 1395f(a)(7)(A)) is amended--
            (1) in clause (i)(I), by striking ``does not include a 
        nurse practitioner'' and inserting ``only includes a physician 
        assistant if a physician has delegated the authority to make 
        the certification required under this paragraph to such 
        physician assistant''; and
            (2) by amending clause (ii) to read as follows:
                            ``(ii) in a subsequent 90- or 60-day 
                        period--
                                    ``(I) the medical director or 
                                physician described in clause (i)(II);
                                    ``(II) a physician employed by the 
                                hospice program providing (or arranging 
                                for) the care or providing care to the 
                                individual under arrangement with such 
                                hospice program;
                                    ``(III) a nurse practitioner 
                                employed by such hospice program or 
                                providing care to the individual under 
                                arrangement with such hospice program; 
                                or
                                    ``(IV) a physician assistant 
                                employed by such hospice program or 
                                providing care to the individual under 
                                arrangement with such hospice program, 
                                provided that an individual described 
                                in subclause (I) or (II) has delegated 
                                the authority to make the 
                                recertification required under this 
                                clause to such physician assistant,
                        recertifies at the beginning of the period that 
                        the individual is terminally ill based on such 
                        clinical judgment;''.
    (c) Effective Date.--The amendments made by this section shall 
apply to items and services furnished on or after January 1, 2017.

SEC. 14. IMPROVING CARE PLANNING FOR MEDICARE HOME HEALTH SERVICES.

    (a) Part A Provisions.--Section 1814(a) of the Social Security Act 
(42 U.S.C. 1395f(a)) is amended--
            (1) in paragraph (2)--
                    (A) in the matter preceding subparagraph (A), by 
                inserting ``, a nurse practitioner or clinical nurse 
                specialist who is working in collaboration with a 
                physician in accordance with State law, a certified 
                nurse-midwife (as defined in section 1861(gg)) as 
                authorized by State law, or a physician assistant (as 
                defined in section 1861(aa)(5)) under the supervision 
                of a physician'' after ``1866(j)''; and
                    (B) in subparagraph (C)--
                            (i) by inserting ``, a nurse practitioner, 
                        a clinical nurse specialist, a certified nurse-
                        midwife, or a physician assistant (as the case 
                        may be)'' after ``physician'' the first 2 times 
                        it appears; and
                            (ii) by striking ``, and, in the case of a 
                        certification made by a physician'' and all 
                        that follows through ``face-to-face encounter'' 
                        and inserting ``, and, in the case of a 
                        certification made by a physician after January 
                        1, 2010, or by a nurse practitioner, clinical 
                        nurse specialist, certified nurse-midwife, or 
                        physician assistant (as the case may be) after 
                        January 1, 2017, prior to making such 
                        certification the physician, nurse 
                        practitioner, clinical nurse specialist, 
                        certified nurse-midwife, or physician assistant 
                        must document that the physician, nurse 
                        practitioner, clinical nurse specialist, 
                        certified nurse-midwife, or physician assistant 
                        has had a face-to-face encounter''; and
            (2) in the flush matter following paragraph (8)--
                    (A) in the first sentence, by inserting ``certified 
                nurse-midwife,'' after ``clinical nurse specialist,'';
                    (B) in the second sentence--
                            (i) by striking ``physician certification'' 
                        and inserting ``certification'';
                            (ii) by inserting ``(or on January 1, 2017, 
                        in the case of regulations to implement the 
                        amendments made by section 14 of the Craig 
                        Thomas Rural Hospital and Provider Equity Act 
                        of 2016)'' after ``1981''; and
                            (iii) by striking ``a physician who'' and 
                        inserting ``a physician, nurse practitioner, 
                        clinical nurse specialist, certified nurse-
                        midwife, or physician assistant who''; and
                    (C) in the third sentence, by inserting ``, nurse 
                practitioner, clinical nurse specialist, certified 
                nurse-midwife, or physician assistant'' after 
                ``physician''.
    (b) Part B Provisions.--Section 1835(a) of the Social Security Act 
(42 U.S.C. 1395n(a)) is amended--
            (1) in paragraph (2)--
                    (A) in the matter preceding subparagraph (A), by 
                inserting ``, a nurse practitioner or clinical nurse 
                specialist (as those terms are defined in section 
                1861(aa)(5)) who is working in collaboration with a 
                physician in accordance with State law, a certified 
                nurse-midwife (as defined in section 1861(gg)) as 
                authorized by State law, or a physician assistant (as 
                defined in section 1861(aa)(5)) under the supervision 
                of a physician'' after ``1866(j)''; and
                    (B) in subparagraph (A)--
                            (i) in each of clauses (ii) and (iii) of 
                        subparagraph (A), by inserting ``, a nurse 
                        practitioner, a clinical nurse specialist, a 
                        certified nurse-midwife, or a physician 
                        assistant (as the case may be)'' after 
                        ``physician''; and
                            (ii) in clause (iv), by striking ``after 
                        January 1, 2010'' and all that follows through 
                        ``face-to-face encounter'' and inserting ``made 
                        by a physician after January 1, 2010, or by a 
                        nurse practitioner, clinical nurse specialist, 
                        certified nurse-midwife, or physician assistant 
                        (as the case may be) after January 1, 2017, 
                        prior to making such certification the 
                        physician, nurse practitioner, clinical nurse 
                        specialist, certified nurse-midwife, or 
                        physician assistant must document that the 
                        physician, nurse practitioner, clinical nurse 
                        specialist, certified nurse-midwife, or 
                        physician assistant has had a face-to-face 
                        encounter'';
            (2) in the third sentence, by inserting ``, nurse 
        practitioner, clinical nurse specialist, certified nurse-
        midwife, or physician assistant (as the case may be)'' after 
        ``physician'';
            (3) in the fourth sentence--
                    (A) by striking ``physician certification'' and 
                inserting ``certification'';
                    (B) by inserting ``(or on January 1, 2017, in the 
                case of regulations to implement the amendments made by 
                section 14 of the Craig Thomas Rural Hospital and 
                Provider Equity Act of 2016)'' after ``1981''; and
                    (C) by striking ``a physician who'' and inserting 
                ``a physician, nurse practitioner, clinical nurse 
                specialist, certified nurse-midwife, or physician 
                assistant who''; and
            (4) in the fifth sentence, by inserting ``, nurse 
        practitioner, clinical nurse specialist, certified nurse-
        midwife, or physician assistant'' after ``physician''.
    (c) Definition Provisions.--
            (1) Home health services.--Section 1861(m) of the Social 
        Security Act (42 U.S.C. 1395x(m)) is amended--
                    (A) in the matter preceding paragraph (1)--
                            (i) by inserting ``, a nurse practitioner 
                        or a clinical nurse specialist (as those terms 
                        are defined in subsection (aa)(5)), a certified 
                        nurse-midwife (as defined in section 1861(gg)), 
                        or a physician assistant (as defined in 
                        subsection (aa)(5))'' after ``physician'' the 
                        first place it appears; and
                            (ii) by inserting ``, a nurse practitioner, 
                        a clinical nurse specialist, a certified nurse-
                        midwife, or a physician assistant'' after 
                        ``physician'' the second place it appears; and
                    (B) in paragraph (3), by inserting ``, a nurse 
                practitioner, a clinical nurse specialist, a certified 
                nurse-midwife, or a physician assistant'' after 
                ``physician''.
            (2) Home health agency.--Section 1861(o)(2) of the Social 
        Security Act (42 U.S.C. 1395x(o)(2)) is amended--
                    (A) by inserting ``, nurse practitioners or 
                clinical nurse specialists (as those terms are defined 
                in subsection (aa)(5)), certified nurse-midwives (as 
                defined in section 1861(gg)), or physician assistants 
                (as defined in subsection (aa)(5))'' after 
                ``physicians''; and
                    (B) by inserting ``, nurse practitioner, clinical 
                nurse specialist, certified nurse-midwife, physician 
                assistant,'' after ``physician''.
    (d) Home Health Prospective Payment System Provisions.--Section 
1895 of the Social Security Act (42 U.S.C. 1395fff) is amended--
            (1) in subsection (c)(1), by inserting ``, the nurse 
        practitioner or clinical nurse specialist (as those terms are 
        defined in section 1861(aa)(5)), the certified nurse-midwife 
        (as defined in section 1861(gg)), or the physician assistant 
        (as defined in section 1861(aa)(5)),'' after ``physician''; and
            (2) in subsection (e)--
                    (A) in paragraph (1)(A), by inserting ``, a nurse 
                practitioner or clinical nurse specialist (as those 
                terms are defined in section 1861(aa)(5)), a certified 
                nurse-midwife (as defined in section 1861(gg)), or a 
                physician assistant (as defined in section 
                1861(aa)(5))'' after ``physician''; and
                    (B) in paragraph (2)--
                            (i) in the heading, by striking ``Physician 
                        certification'' and inserting ``Rule of 
                        construction regarding requirement for 
                        certification''; and
                            (ii) by striking ``physician''.
    (e) Effective Date.--The amendments made by this section shall 
apply to items and services furnished on or after January 1, 2017.

SEC. 15. RURAL HEALTH CLINIC IMPROVEMENTS.

    Section 1833(f) of the Social Security Act (42 U.S.C. 1395l(f)) is 
amended--
            (1) in paragraph (1), by striking ``, and'' at the end and 
        inserting a semicolon;
            (2) in paragraph (2)--
                    (A) by inserting ``(before 2017)'' after ``in a 
                subsequent year''; and
                    (B) by striking the period at the end and inserting 
                a semicolon; and
            (3) by adding at the end the following new paragraphs:
            ``(3) in 2017, at $110 per visit; and
            ``(4) for years following 2017, at the limit established 
        under this subsection for the previous year increased by the 
        percentage increase in the MEI (as so defined) applicable to 
        primary care services (as so defined) furnished as of the first 
        day of that year.''.

SEC. 16. TEMPORARY MEDICARE PAYMENT INCREASE FOR HOME HEALTH SERVICES 
              FURNISHED IN A RURAL AREA.

    Section 421(a) of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2283), as 
amended by section 5201(b) of the Deficit Reduction Act of 2005 (Public 
Law 109-171; 120 Stat. 46), section 3131(c) of the Patient Protection 
and Affordable Care Act (Public Law 111-148; 124 Stat. 428), and 
section 210 of the Medicare Access and CHIP Reauthorization Act of 2015 
(Public Law 114-10; 129 Stat. 151), is amended by striking ``January 1, 
2018'' and inserting ``January 1, 2019'' each place it appears.

SEC. 17. EXTENSION OF INCREASED MEDICARE PAYMENTS FOR RURAL GROUND 
              AMBULANCE SERVICES.

    (a) In General.--Section 1834(l)(13)(A) of the Social Security Act 
(42 U.S.C. 1395m(l)(13)(A)) is amended--
            (1) in the matter preceding clause (i), by striking ``July 
        1, 2004'' and all that follows through ``originates in'';
            (2) in clause (i)--
                    (A) by inserting ``July 1, 2004, and before January 
                1, 2007, and for such services furnished on or after 
                July 1, 2008, and before January 1, 2019, for which the 
                transportation originates in'' before ``a rural''; and
                    (B) by striking ``2018'' and inserting ``2017, or 5 
                percent if such service is furnished on or after 
                January 1, 2017, and before January 1, 2019''; and
            (3) in clause (ii), by inserting ``July 1, 2004, and before 
        January 1, 2007, and for such services furnished on or after 
        July 1, 2008, and before January 1, 2018, for which the 
        transportation originates in'' before ``an area not''.
    (b) Super Rural Ambulance.--Section 1834(l)(12)(A) of the Social 
Security Act (42 U.S.C. 1395m(l)(12)(A)) is amended by striking 
``January 1, 2018'' and inserting ``January 1, 2019''.

SEC. 18. COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES AND MENTAL 
              HEALTH COUNSELOR SERVICES UNDER PART B OF THE MEDICARE 
              PROGRAM.

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

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

    ``(iii)(1) The term `marriage and family therapist services' means 
services performed by a marriage and family therapist (as defined in 
paragraph (2)) for the diagnosis and treatment of mental illnesses, 
which the marriage and family therapist is legally authorized to 
perform under State law (or the State regulatory mechanism provided by 
State law) of the State in which such services are performed, as would 
otherwise be covered if furnished by a physician or as an incident to a 
physician's professional service, but only if no facility or other 
provider charges or is paid any amounts with respect to the furnishing 
of such services.
    ``(2) The term `marriage and family therapist' means an individual 
who--
            ``(A) possesses a master's or doctoral degree which 
        qualifies for licensure or certification as a marriage and 
        family therapist pursuant to State law;
            ``(B) after obtaining such degree has performed at least 2 
        years of clinical supervised experience in marriage and family 
        therapy; and
            ``(C) in the case of an individual performing services in a 
        State that provides for licensure or certification of marriage 
        and family therapists, is licensed or certified as a marriage 
        and family therapist in such State.
    ``(3) The term `mental health counselor services' means services 
performed by a mental health counselor (as defined in paragraph (4)) 
for the diagnosis and treatment of mental illnesses which the mental 
health counselor is legally authorized to perform under State law (or 
the State regulatory mechanism provided by the State law) of the State 
in which such services are performed, as would otherwise be covered if 
furnished by a physician or as incident to a physician's professional 
service, but only if no facility or other provider charges or is paid 
any amounts with respect to the furnishing of such services.
    ``(4) The term `mental health counselor' means an individual who--
            ``(A) possesses a master's or doctor's degree in mental 
        health counseling or a related field;
            ``(B) after obtaining such a degree has performed at least 
        2 years of supervised mental health counselor practice; and
            ``(C) in the case of an individual performing services in a 
        State that provides for licensure or certification of mental 
        health counselors or professional counselors, is licensed or 
        certified as a mental health counselor or professional 
        counselor in such State.''.
            (3) Provision for payment under part b.--Section 
        1832(a)(2)(B) of the Social Security Act (42 U.S.C. 
        1395k(a)(2)(B)) is amended by adding at the end the following 
        new clause:
                            ``(v) marriage and family therapist 
                        services (as defined in section 1861(iii)(1)) 
                        and mental health counselor services (as 
                        defined in section 1861(iii)(3));''.
            (4) Amount of payment.--Section 1833(a)(1) of the Social 
        Security Act (42 U.S.C. 1395l(a)(1)) is amended--
                    (A) by striking ``and (AA)'' and inserting 
                ``(AA)''; and
                    (B) by inserting before the semicolon at the end 
                the following: ``, and (BB) with respect to marriage 
                and family therapist services and mental health 
                counselor services under section 1861(s)(2)(GG), the 
                amounts paid shall be 80 percent of the lesser of the 
                actual charge for the services or 75 percent of the 
                amount determined for payment of a psychologist under 
                subparagraph (L)''.
            (5) Exclusion of marriage and family therapist services and 
        mental health counselor services from skilled nursing facility 
        prospective payment system.--Section 1888(e)(2)(A)(ii) of the 
        Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended 
        by inserting ``marriage and family therapist services (as 
        defined in section 1861(iii)(1)), mental health counselor 
        services (as defined in section 1861(iii)(3)),'' after 
        ``qualified psychologist services,''.
            (6) Inclusion of marriage and family therapists and mental 
        health counselors as practitioners for assignment of claims.--
        Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 
        1395u(b)(18)(C)) is amended by adding at the end the following 
        new clauses:
            ``(vii) A marriage and family therapist (as defined in 
        section 1861(iii)(2)).
            ``(viii) A mental health counselor (as defined in section 
        1861(iii)(4)).''.
    (b) Coverage of Certain Mental Health Services Provided in Certain 
Settings.--
            (1) Rural health clinics and federally qualified health 
        centers.--Section 1861(aa)(1)(B) of the Social Security Act (42 
        U.S.C. 1395x(aa)(1)(B)) is amended by striking ``or by a 
        clinical social worker (as defined in subsection (hh)(1))'' and 
        inserting ``, by a clinical social worker (as defined in 
        subsection (hh)(1)), by a marriage and family therapist (as 
        defined in subsection (iii)(2)), or by a mental health 
        counselor (as defined in subsection (iii)(4))''.
            (2) Hospice programs.--Section 1861(dd)(2)(B)(i)(III) of 
        the Social Security Act (42 U.S.C. 1395x(dd)(2)(B)(i)(III)) is 
        amended by inserting ``, marriage and family therapist, or 
        mental health counselor'' after ``social worker''.
    (c) Authorization of Marriage and Family Therapists and Mental 
Health Counselors To Develop Discharge Plans for Post-Hospital 
Services.--Section 1861(ee)(2)(G) of the Social Security Act (42 U.S.C. 
1395x(ee)(2)(G)) is amended by inserting ``, including a marriage and 
family therapist and a mental health counselor who meets qualification 
standards established by the Secretary'' before the period at the end.
    (d) Effective Date.--The amendments made by this section shall 
apply with respect to services furnished on or after January 1, 2017.

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

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

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

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

    ``Anesthesiologist Services Provided in Certain Rural Hospitals

    ``(m)(1) Notwithstanding any other provision of this title, 
coverage and payment shall be provided under this part for physicians' 
services that are anesthesia services furnished by a physician who is 
an anesthesiologist in a rural hospital described in paragraph (3) in 
the same manner as payment is made under the exception provided in 
section 9320(k) of the Omnibus Budget Reconciliation Act of 1986, as 
amended by section 6132 of the Omnibus Budget Reconciliation Act of 
1989 (42 U.S.C. 1395k note) (relating to payment on a reasonable cost, 
pass-through basis), for certified registered nurse anesthetist 
services furnished by a certified registered nurse anesthetist in a 
hospital described in such section.
    ``(2) No payment shall be made under any other provision of this 
title for physicians' services for which payment is made under this 
subsection.
    ``(3) A rural hospital described in this paragraph is a hospital 
described in section 9320(k) of the Omnibus Budget Reconciliation Act 
of 1986, as so amended (42 U.S.C. 1395k note), except that--
            ``(A) any reference in such section to a `certified 
        registered nurse anesthetist' or `anesthetist' is deemed a 
        reference to a `physician who is an anesthesiologist' or 
        `anesthesiologist', respectively; and
            ``(B) any reference to `January 1, 1988' or `1987' is 
        deemed a reference to such date and year as the Secretary shall 
        specify.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to services furnished during cost reporting periods beginning on 
or after the date of the enactment of this Act.

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

    Section 1848(e)(1) of the Social Security Act (42 U.S.C. 1395w-
4(e)(1)) is amended by adding at the end the following new 
subparagraph:
                    ``(J) Floor at 1.0 on practice expense geographic 
                index for services furnished in rural areas outside of 
                frontier states.--For purposes of payment for services 
                furnished in a rural area (other than a rural area 
                located in a State to which subparagraph (I) applies) 
                on or after January 1, 2017, and before January 1, 
                2018, after calculating the practice expense index 
                under subparagraph (A)(i), the Secretary shall increase 
                any such index to 1.0 if such index would otherwise be 
                less than 1.0. The preceding sentence shall not be 
                applied in a budget neutral manner.''.

SEC. 22. REVISIONS TO STANDARD FOR DESIGNATION OF SOLE COMMUNITY 
              HOSPITALS.

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

SEC. 23. MEDICARE TREATMENT OF STANDBY AND ON-CALL TIME FOR CRNA 
              SERVICES.

    (a) In General.--Section 9320(k) of the Omnibus Budget 
Reconciliation Act of 1986 (42 U.S.C. 1395k note), as added by section 
608(c)(2) of the Family Support Act of 1988 and amended by section 6132 
of the Omnibus Budget Reconciliation Act of 1989, is amended by adding 
at the end the following:
            ``(3) In determining the reasonable costs incurred by a 
        hospital or critical access hospital for the services of a 
        certified registered nurse anesthetist under this subsection, 
        the Secretary shall include standby costs and on-call costs 
        incurred by the hospital or critical access hospital, 
        respectively, with respect to such nurse anesthetist.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to costs incurred in cost reporting periods beginning in fiscal 
years after fiscal year 2007 and before fiscal year 2017.

SEC. 24. STATE OFFICES OF RURAL HEALTH.

    Section 338J of the Public Health Service Act (42 U.S.C. 254r) is 
amended to read as follows:

``SEC. 338J. GRANTS TO STATE OFFICES OF RURAL HEALTH.

    ``(a) In General.--The Secretary, acting through the Director of 
the Federal Office of Rural Health Policy (established under section 
711 of the Social Security Act), shall make grants to each State Office 
of Rural Health for the purpose of improving health care in rural 
areas.
    ``(b) Requirement of Matching Funds.--
            ``(1) In general.--Subject to paragraph (2), the Secretary 
        may not make a grant under subsection (a) unless the State 
        office of rural health involved agrees, with respect to the 
        costs to be incurred in carrying out the purpose described in 
        such subsection, to provide non-Federal contributions toward 
        such costs in an amount equal to $3 for each $1 of Federal 
        funds provided in the grant.
            ``(2) Waiver or reduction.--The Secretary is authorized to 
        waive or reduce the non-Federal contribution if the State 
        office of rural health can demonstrate that requiring matching 
        funds would limit its ability to carry out the purpose 
        described in subsection (a).
            ``(3) Determination of amount of non-federal 
        contribution.--Non-Federal contributions required in paragraph 
        (1) may be in cash or in kind, fairly evaluated, including 
        plant, equipment, or services. Amounts provided by the Federal 
        Government, or services assisted or subsidized to any 
        significant extent by the Federal Government, may not be 
        included in determining the amount of such non-Federal 
        contributions.
    ``(c) Certain Required Activities.--Recipients of a grant under 
subsection (a) shall use the grant funds for purposes of--
            ``(1) maintaining within the State office of rural health a 
        clearinghouse for collecting and disseminating information on--
                    ``(A) rural health care issues;
                    ``(B) research findings relating to rural health 
                care; and
                    ``(C) innovative approaches to the delivery of 
                health care in rural areas;
            ``(2) coordinating the activities carried out in the State 
        that relate to rural health care, including providing 
        coordination for the purpose of avoiding redundancy in such 
        activities; and
            ``(3) identifying Federal and State programs regarding 
        rural health, and providing technical assistance to public and 
        nonprofit private entities regarding participation in such 
        programs.
    ``(d) Requirement Regarding Annual Budget for Office.--The 
Secretary may not make a grant under subsection (a) unless the State 
involved agrees that, for any fiscal year for which the State office of 
rural health receives such a grant, the office operated pursuant to 
subsection (a) of this section will be provided with an annual budget 
of not less than $150,000.
    ``(e) Certain Uses of Funds.--
            ``(1) Restrictions.--The Secretary may not make a grant 
        under subsection (a) unless the State office of rural health 
        involved agrees that the grant will not be expended--
                    ``(A) to provide health care (including providing 
                cash payments regarding such care);
                    ``(B) to conduct activities for which Federal funds 
                are expended--
                            ``(i) within the State to provide technical 
                        and other nonfinancial assistance under section 
                        330A(f);
                            ``(ii) under a memorandum of agreement 
                        entered into with the State office of rural 
                        health under section 330A(h); or
                            ``(iii) under a grant under section 338I;
                    ``(C) to purchase medical equipment, to purchase 
                ambulances, aircraft, or other vehicles, or to purchase 
                major communications equipment;
                    ``(D) to purchase or improve real property; or
                    ``(E) to carry out any activity regarding a 
                certificate of need.
            ``(2) Authorities.--Activities for which a State office of 
        rural health may expend a grant under subsection (a) include--
                    ``(A) paying the costs of maintaining an office of 
                rural health for purposes of subsection (a);
                    ``(B) subject to paragraph (1)(B)(iii), paying the 
                costs of any activity carried out with respect to 
                recruiting and retaining health professionals to serve 
                in rural areas of the State; and
                    ``(C) providing grants and contracts to public and 
                nonprofit private entities to carry out activities 
                authorized in this section.
            ``(3) Limit on indirect costs.--The Secretary may impose a 
        limit of no more than 15 percent on indirect costs claimed by 
        the recipient of the grant.
    ``(f) Reports.--The Secretary may not make a grant under subsection 
(a) unless the State office of rural health involved agrees--
            ``(1) to submit to the Secretary reports or performance 
        data containing such information as the Secretary may require 
        regarding activities carried out under this section; and
            ``(2) to submit such a report or performance data not later 
        than than September 30 of any fiscal year for which the State 
        office of rural health has received such a grant.
    ``(g) Requirement of Application.--The Secretary may not make a 
grant under subsection (a) unless an application for the grant is 
submitted to the Secretary and the application is in such form, is made 
in such manner, and contains such agreements, assurances, and 
information as the Secretary determines to be necessary to carry out 
such subsection.
    ``(h) Noncompliance.--The Secretary may not make payments under 
subsection (a) to a State office of rural health for any fiscal year 
subsequent to the first fiscal year of such payments unless the 
Secretary determines that, for the immediately preceding fiscal year, 
the State office of rural health has complied with each of the 
agreements made by the State office of rural health under this section.
    ``(i) Authorization of Appropriations.--
            ``(1) In general.--For the purpose of making grants under 
        subsection (a), there are authorized to be appropriated such 
        sums as may be necessary for each of fiscal years 2017 through 
        2021.
            ``(2) Availability.--Amounts appropriated under paragraph 
        (1) shall remain available until expended.''.

SEC. 25. REMOVING MEDICARE 96-HOUR PHYSICIAN CERTIFICATION REQUIREMENT 
              FOR INPATIENT CRITICAL ACCESS HOSPITAL SERVICES.

    (a) In General.--Section 1814(a) of the Social Security Act (42 
U.S.C. 1395f(a)), is amended--
            (1) in paragraph (6), by adding ``and'' at the end;
            (2) in paragraph (7), at the end of subparagraph (E), by 
        striking ``; and'' and inserting a period; and
            (3) by striking paragraph (8).
    (b) Application.--The amendments made by subsection (a) shall apply 
with respect to items and services furnished on or after January 1, 
2017.

SEC. 26. EXTENSION OF ENFORCEMENT INSTRUCTION ON SUPERVISION 
              REQUIREMENTS FOR OUTPATIENT THERAPEUTIC SERVICES IN 
              CRITICAL ACCESS AND SMALL RURAL HOSPITALS THROUGH 2017.

    Section 1 of Public Law 113-198, as amended by section 1 of Public 
Law 114-112, is amended--
            (1) in the section heading, by striking ``and 2015'' and 
        inserting ``, 2015, 2016, and 2017''; and
            (2) by striking ``and 2015'' and inserting ``, 2015, 2016, 
        and 2017''.

SEC. 27. MEDICARE PAYMENT FOR CERTAIN RURAL HEALTH CLINIC AND FEDERALLY 
              QUALIFIED HEALTH CENTER SERVICES FURNISHED TO HOSPICE 
              PATIENTS.

    (a) In General.--Section 1812(d)(2) of the Social Security Act (42 
U.S.C. 1395d(d)(2)) is amended--
            (1) in subparagraph (A)--
                    (A) in the matter preceding clause (i), by striking 
                ``subparagraphs (B) and (C)'' and inserting ``the 
                succeeding provisions of this paragraph'';
                    (B) in clause (ii)(II), by striking the semicolon 
                at the end and inserting a period; and
                    (C) by striking the flush matter following clause 
                (ii)(II); and
            (2) by adding at the end the following new subparagraph:
            ``(E) Subparagraph (A)(ii) shall not apply to--
                    ``(i) physicians' services furnished by the 
                individual's attending physician (as defined in section 
                1861(dd)(3)(B)), if not an employee of the hospice 
                program;
                    ``(ii) services provided by (or under arrangements 
                made by) the hospice program; or
                    ``(iii) rural health clinic services (as defined in 
                paragraph (1) of section 1861(aa)) and Federally 
                qualified health center services (as defined in 
                paragraph (3) of such section) if such services--
                            ``(I) would otherwise be physicians' 
                        services if furnished by an individual not 
                        affiliated with a rural health clinic (as 
                        defined in paragraph (2) of such section) or a 
                        Federally qualified health center (as defined 
                        in paragraph (4) of such section); and
                            ``(II) are--
                                    ``(aa) furnished by the 
                                individual's attending physician (as so 
                                defined), if not an employee of the 
                                hospice program; or
                                    ``(bb) provided under arrangements 
                                made by the hospice program.''.
    (b) Effective Date.--The amendments made by this section shall 
apply to services furnished on or after the date that is six months 
after the date of the enactment of this Act.
                                 <all>
```