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† HR 1892 EAS2 
lessness, homeless veterans, and veterans at risk 
of homelessness’’; and 
(B) in paragraph (5)— 
(i) by striking subparagraph (B); 
(ii) by redesignating subparagraph (C) 
as subparagraph (B); and 
(iii) in subparagraph (B) (as so redes-
ignated)— 
(I) in the subparagraph heading, 
by striking ‘‘ABUSE’’ and inserting 
‘‘USE DISORDER’’; and 
(II) by striking ‘‘abuse’’ and in-
serting ‘‘use disorder’’; 
(9) in subsection (k)— 
(A) in paragraph (2)— 
(i) in the paragraph heading, by in-
serting ‘‘UNMET’’ before ‘‘NEED’’; 
(ii) in the matter preceding subpara-
graph (A), by inserting ‘‘or subsection 
(e)(6)’’ after ‘‘subsection (e)(1)’’; 
(iii) in subparagraph (A), by inserting 
‘‘unmet’’ before ‘‘need for health services’’; 
(iv) in subparagraph (B), by striking 
‘‘and’’ at the end;
566 
† HR 1892 EAS2 
(v) in subparagraph (C), by striking 
the period at the end and inserting ‘‘; and’’; 
and 
(vi) by adding after subparagraph (C) 
the following: 
‘‘(D) in the case of an application for a 
grant pursuant to subsection (e)(6), a dem-
onstration that the applicant has consulted with 
appropriate State and local government agen-
cies, and health care providers regarding the 
need for the health services to be provided at the 
proposed delivery site.’’; 
(B) in paragraph (3)— 
(i) in the matter preceding subpara-
graph (A), by inserting ‘‘or subsection 
(e)(6)’’ after ‘‘subsection (e)(1)(B)’’; 
(ii) in subparagraph (B), by striking 
‘‘in the catchment area of the center’’ and 
inserting ‘‘, including other health care pro-
viders 
that 
provide 
care 
within 
the 
catchment area, local hospitals, and spe-
cialty providers in the catchment area of 
the center, to provide access to services not 
available through the health center and to
567 
† HR 1892 EAS2 
reduce the non-urgent use of hospital emer-
gency departments’’; 
(iii) in subparagraph (H)(ii), by in-
serting ‘‘who shall be directly employed by 
the center’’ after ‘‘approves the selection of 
a director for the center’’; 
(iv) in subparagraph (L), by striking 
‘‘and’’ at the end; 
(v) in subparagraph (M), by striking 
the period and inserting ‘‘; and’’; and 
(vi) by inserting after subparagraph 
(M), the following: 
‘‘(N) the center has written policies and 
procedures in place to ensure the appropriate use 
of Federal funds in compliance with applicable 
Federal statutes, regulations, and the terms and 
conditions of the Federal award.’’; and 
(C) by striking paragraph (4); 
(10) in subsection (l), by adding at the end the 
following: ‘‘Funds expended to carry out activities 
under this subsection and operational support activi-
ties under subsection (m) shall not exceed 3 percent 
of the amount appropriated for this section for the fis-
cal year involved.’’;
568 
† HR 1892 EAS2 
(11) in subsection (q)(4), by adding at the end 
the following: ‘‘A waiver provided by the Secretary 
under this paragraph may not remain in effect for 
more than 1 year and may not be extended after such 
period. An entity may not receive more than one 
waiver under this paragraph in consecutive years.’’; 
(12) in subsection (r)(3)— 
(A) by striking ‘‘appropriate committees of 
Congress a report concerning the distribution of 
funds under this section’’ and inserting the fol-
lowing: ‘‘Committee on Health, Education, 
Labor, and Pensions of the Senate, and the Com-
mittee on Energy and Commerce of the House of 
Representatives, a report including, at a min-
imum— 
‘‘(A) the distribution of funds for carrying 
out this section’’; 
(B) by striking ‘‘populations. Such report 
shall include an assessment’’ and inserting the 
following: ‘‘populations; 
‘‘(B) an assessment’’; 
(C) by striking ‘‘and the rationale for any 
substantial changes in the distribution of funds.’’ 
and inserting a semicolon; and 
(D) by adding at the end the following:
569 
† HR 1892 EAS2 
‘‘(C) the distribution of awards and funding 
for new or expanded services in each of rural 
areas and urban areas; 
‘‘(D) the distribution of awards and fund-
ing for establishing new access points, and the 
number of new access points created; 
‘‘(E) the amount of unexpended funding for 
loan guarantees and loan guarantee authority 
under title XVI; 
‘‘(F) the rationale for any substantial 
changes in the distribution of funds; 
‘‘(G) the rate of closures for health centers 
and access points; 
‘‘(H) the number and reason for any grants 
awarded pursuant to subsection (e)(1)(B); and 
‘‘(I) the number and reason for any waivers 
provided pursuant to subsection (q)(4).’’; 
(13) in subsection (r), by adding at the end the 
following new paragraph: 
‘‘(5) FUNDING FOR PARTICIPATION OF HEALTH 
CENTERS IN ALL OF US RESEARCH PROGRAM.—In ad-
dition to any amounts made available pursuant to 
paragraph (1) of this subsection, section 402A of this 
Act, or section 10503 of the Patient Protection and 
Affordable Care Act, there is authorized to be appro-
570 
† HR 1892 EAS2 
priated, and there is appropriated, out of any monies 
in the Treasury not otherwise appropriated, to the 
Secretary $25,000,000 for fiscal year 2018 to support 
the participation of health centers in the All of Us 
Research Program under the Precision Medicine Ini-
tiative under section 498E of this Act.’’; and 
(14) by striking subsection (s). 
(c) NATIONAL HEALTH SERVICE CORPS.—Section 
10503(b)(2)(F) of the Patient Protection and Affordable 
Care Act (42 U.S.C. 254b–2(b)(2)(F)), as amended by sec-
tion 3101 of Public Law 115–96, is amended to read as 
follows: 
‘‘(F) $310,000,000 for each of fiscal years 
2018 and 2019.’’. 
(d) TEACHING HEALTH CENTERS THAT OPERATE 
GRADUATE MEDICAL EDUCATION PROGRAMS.— 
(1) PAYMENTS.—Subsection (a) of section 340H 
of the Public Health Service Act (42 U.S.C. 256h) is 
amended to read as follows: 
‘‘(a) PAYMENTS.— 
‘‘(1) IN GENERAL.—Subject to subsection (h)(2), 
the Secretary shall make payments under this section 
for direct expenses and indirect expenses to qualified 
teaching health centers that are listed as sponsoring
573 
† HR 1892 EAS2 
tion of a primary care residency program in sec-
tion 749A). 
‘‘(G) Of the number of residents described in 
paragraph (4) who completed their residency 
training at the end of such residency academic 
year, the number and percentage of such resi-
dents who entered practice at a health care facil-
ity— 
‘‘(i) primarily serving a health profes-
sional shortage area with a designation in 
effect under section 332 or a medically un-
derserved community (as defined in section 
799B); or 
‘‘(ii) located in a rural area (as de-
fined in section 1886(d)(2)(D) of the Social 
Security Act).’’. 
(4) REPORT
ON
TRAINING
COSTS.—Not later 
than March 31, 2019, the Secretary of Health and 
Human Services shall submit to the Congress a report 
on the direct graduate expenses of approved graduate 
medical residency training programs, and the indi-
rect expenses associated with the additional costs of 
teaching residents, of qualified teaching health centers 
(as such terms are used or defined in section 340H 
of the Public Health Service Act (42 U.S.C. 256h)).
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† HR 1892 EAS2 
(5) DEFINITION.—Subsection (j) of section 340H 
of the Public Health Service Act (42 U.S.C. 256h) is 
amended— 
(A) by redesignating paragraphs (2) and 
(3) as paragraphs (3) and (4), respectively; and 
(B) by inserting after paragraph (1) the fol-
lowing: 
‘‘(2) NEW APPROVED GRADUATE MEDICAL RESI-
DENCY TRAINING PROGRAM.—The term ‘new approved 
graduate medical residency training program’ means 
an approved graduate medical residency training 
program for which the sponsoring qualified teaching 
health center has not received a payment under this 
section for a previous fiscal year (other than pursuant 
to subsection (a)(1)(C)).’’. 
(6) TECHNICAL CORRECTION.—Subsection (f) of 
section 340H (42 U.S.C. 256h) is amended by strik-
ing ‘‘hospital’’ each place it appears and inserting 
‘‘teaching health center’’. 
(7) PAYMENTS FOR PREVIOUS FISCAL YEARS.— 
The provisions of section 340H of the Public Health 
Service Act (42 U.S.C. 256h), as in effect on the day 
before the date of enactment of Public Law 115–96, 
shall continue to apply with respect to payments
575 
† HR 1892 EAS2 
under such section for fiscal years before fiscal year 
2018. 
(e) APPLICATION.—Amounts appropriated pursuant to 
this section for fiscal year 2018 or 2019 are subject to the 
requirements contained in Public Law 115–31 for funds for 
programs authorized under sections 330 through 340 of the 
Public Health Service Act (42 U.S.C. 254b–256). 
(f) CONFORMING AMENDMENTS.—Paragraph (4) of 
section 3014(h) of title 18, United States Code, as amended 
by section 3101 of Public Law 115–96, is amended by strik-
ing ‘‘and section 3101(d) of the CHIP and Public Health 
Funding Extension Act’’ and inserting ‘‘and section 
50901(e) of the Advancing Chronic Care, Extenders, and 
Social Services Act’’. 
SEC. 50902. EXTENSION FOR SPECIAL DIABETES PRO-
GRAMS. 
(a) SPECIAL DIABETES PROGRAM FOR TYPE I DIABE-
TES.—Section 330B(b)(2)(D) of the Public Health Service 
Act (42 U.S.C. 254c–2(b)(2)(D)), as amended by section 
3102 of Public Law 115–96, is amended to read as follows: 
‘‘(D) $150,000,000 for each of fiscal years 
2018 and 2019, to remain available until ex-
pended.’’. 
(b) SPECIAL DIABETES PROGRAM FOR INDIANS.—Sub-
paragraph (D) of section 330C(c)(2) of the Public Health
576 
† HR 1892 EAS2 
Service Act (42 U.S.C. 254c–3(c)(2)), as amended by sec-
tion 3102 of Public Law 115–96, is amended to read as 
follows: 
‘‘(D) $150,000,000 for each of fiscal years 
2018 and 2019, to remain available until ex-
pended.’’. 
TITLE X—MISCELLANEOUS 
HEALTH CARE POLICIES 
SEC. 51001. HOME HEALTH PAYMENT REFORM. 
(a) BUDGET NEUTRAL TRANSITION TO A 30-DAY UNIT 
OF PAYMENT
FOR HOME HEALTH SERVICES.—Section 
1895(b) of the Social Security Act (42 U.S.C. 1395fff(b)) 
is amended— 
(1) in paragraph (2)— 
(A) by striking ‘‘PAYMENT.—In defining’’ 
and inserting ‘‘PAYMENT.— 
‘‘(A) IN GENERAL.—In defining’’; and 
(B) by adding at the end the following new 
subparagraph: 
‘‘(B) 30-DAY UNIT OF SERVICE.—For pur-
poses of implementing the prospective payment 
system with respect to home health units of serv-
ice furnished during a year beginning with 
2020, the Secretary shall apply a 30-day unit of
577 
† HR 1892 EAS2 
service as the unit of service applied under this 
paragraph.’’; 
(2) in paragraph (3)— 
(A) in subparagraph (A), by adding at the 
end the following new clause: 
‘‘(iv) BUDGET NEUTRALITY FOR 2020.— 
With respect to payments for home health 
units of service furnished that end during 
the 12-month period beginning January 1, 
2020, the Secretary shall calculate a stand-
ard 
prospective 
payment 
amount 
(or 
amounts) for 30-day units of service (as de-
scribed in paragraph (2)(B)) for the pro-
spective payment system under this sub-
section. Such standard prospective payment 
amount (or amounts) shall be calculated in 
a manner such that the estimated aggregate 
amount of expenditures under the system 
during such period with application of 
paragraph (2)(B) is equal to the estimated 
aggregate amount of expenditures that oth-
erwise would have been made under the sys-
tem during such period if paragraph (2)(B) 
had not been enacted. The previous sentence 
shall be applied before (and not affect the
578 
† HR 1892 EAS2 
application of) paragraph (3)(B). In calcu-
lating such amount (or amounts), the Sec-
retary shall make assumptions about behav-
ior changes that could occur as a result of 
the implementation of paragraph (2)(B) 
and the case-mix adjustment factors estab-
lished under paragraph (4)(B) and shall 
provide a description of such assumptions 
in the notice and comment rulemaking used 
to implement this clause.’’; and 
(B) by adding at the end the following new 
subparagraph: 
‘‘(D) BEHAVIOR ASSUMPTIONS AND ADJUST-
MENTS.— 
‘‘(i) IN GENERAL.—The Secretary shall 
annually determine the impact of dif-
ferences between assumed behavior changes 
(as described in paragraph (3)(A)(iv)) and 
actual behavior changes on estimated aggre-
gate expenditures under this subsection with 
respect to years beginning with 2020 and 
ending with 2026. 
‘‘(ii) PERMANENT ADJUSTMENTS.—The 
Secretary shall, at a time and in a manner 
determined appropriate, through notice and
579 
† HR 1892 EAS2 
comment rulemaking, provide for one or 
more permanent increases or decreases to 
the standard prospective payment amount 
(or amounts) for applicable years, on a pro-
spective basis, to offset for such increases or 
decreases in estimated aggregate expendi-
tures (as determined under clause (i)). 
‘‘(iii) TEMPORARY ADJUSTMENTS FOR 
RETROSPECTIVE BEHAVIOR.—The Secretary 
shall, at a time and in a manner deter-
mined appropriate, through notice and 
comment rulemaking, provide for one or 
more temporary increases or decreases to 
the payment amount for a unit of home 
health services (as determined under para-
graph (4)) for applicable years, on a pro-
spective basis, to offset for such increases or 
decreases in estimated aggregate expendi-
tures (as determined under clause (i)). Such 
a temporary increase or decrease shall 
apply only with respect to the year for 
which such temporary increase or decrease 
is made, and the Secretary shall not take 
into account such a temporary increase or
580 
† HR 1892 EAS2 
decrease in computing such amount under 
this subsection for a subsequent year.’’; and 
(3) in paragraph (4)(B)— 
(A) by striking ‘‘FACTORS.—The Secretary’’ 
and inserting ‘‘FACTORS.— 
‘‘(i) IN
GENERAL.—The Secretary’’; 
and 
(B) by adding at the end the following new 
clause: 
‘‘(ii) 
TREATMENT
OF
THERAPY 
THRESHOLDS.—For 2020 and subsequent 
years, the Secretary shall eliminate the use 
of therapy thresholds (established by the 
Secretary) in case mix adjustment factors 
established under clause (i) for calculating 
payments under the prospective payment 
system under this subsection.’’. 
(b) TECHNICAL EXPERT PANEL.— 
(1) IN GENERAL.—During the period beginning 
on January 1, 2018, and ending on December 31, 
2018, the Secretary of Health and Human Services 
shall hold at least one session of a technical expert 
panel, the participants of which shall include home 
health providers, patient representatives, and other 
relevant stakeholders. The technical expert panel shall
581 
† HR 1892 EAS2 
identify and prioritize recommendations with respect 
to the prospective payment system for home health 
services under section 1895(b) of the Social Security 
Act (42 U.S.C. 1395fff(b)), on the following: 
(A) The Home Health Groupings Model, as 
described in the proposed rule ‘‘Medicare and 
Medicaid Programs; CY 2018 Home Health Pro-
spective Payment System Rate Update and Pro-
posed CY 2019 Case-Mix Adjustment Method-
ology Refinements; Home Health Value-Based 
Purchasing Model; and Home Health Quality 
Reporting Requirements’’ (82 Fed. Reg. 35294 
through 35332 (July 28, 2017)). 
(B) Alternative case-mix models to the 
Home Health Groupings Model that were sub-
mitted during 2017 as comments in response to 
proposed rule making, including patient-focused 
factors that consider the risks of hospitalization 
and readmission to a hospital, improvement or 
maintenance of functionality of individuals to 
increase the capacity for self-care, quality of 
care, and resource utilization. 
(2) INAPPLICABILITY OF FACA.—The provisions 
of the Federal Advisory Committee Act (5 U.S.C.
582 
† HR 1892 EAS2 
App.) shall not apply to the technical expert panel 
under paragraph (1). 
(3) REPORT.—Not later than April 1, 2019, the 
Secretary of Health and Human Services shall sub-
mit to the Committee on Ways and Means and the 
Committee on Energy and Commerce of the House of 
Representatives and the Committee on Finance of the 
Senate a report on the recommendations of such panel 
described in such paragraph. 
(4) NOTICE AND COMMENT RULEMAKING.—Not 
later than December 31, 2019, the Secretary of Health 
and Human Services shall pursue notice and com-
ment rulemaking on a case-mix system with respect 
to the prospective payment system for home health 
services under section 1895(b) of the Social Security 
Act (42 U.S.C. 1395fff(b)). 
(c) REPORTS.— 
(1) INTERIM REPORT.—Not later than March 15, 
2022, the Medicare Payment Advisory Commission 
shall submit to Congress an interim report on the ap-
plication of a 30-day unit of service as the unit of 
service applied under section 1895(b)(2) of the Social 
Security Act (42 U.S.C. 1395fff(b)(2)), as amended by 
subsection (a), including an analysis of the level of 
payments provided to home health agencies as com-
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† HR 1892 EAS2 
pared to the cost of delivering home health services, 
and any unintended consequences, including with re-
spect to behavioral changes and quality. 
(2) FINAL REPORT.—Not later than March 15, 
2026, such Commission shall submit to Congress a 
final report on such application and any such con-
sequences. 
SEC. 51002. INFORMATION TO SATISFY DOCUMENTATION 
OF 
MEDICARE 
ELIGIBILITY 
FOR 
HOME 
HEALTH SERVICES. 
(a) PART A.—Section 1814(a) of the Social Security 
Act (42 U.S.C. 1395f(a)) is amended by inserting before 
‘‘For purposes of paragraph (2)(C),’’ the following new sen-
tence: ‘‘For purposes of documentation for physician certifi-
cation and recertification made under paragraph (2) on or 
after January 1, 2019, and made with respect to home 
health services furnished by a home health agency, in addi-
tion to using documentation in the medical record of the 
physician who so certifies or the medical record of the acute 
or post-acute care facility (in the case that home health 
services were furnished to an individual who was directly 
admitted to the home health agency from such a facility), 
the Secretary may use documentation in the medical record 
of the home health agency as supporting material, as appro-
priate to the case involved.’’.
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† HR 1892 EAS2 
(b) PART B.—Section 1835(a) of the Social Security 
Act (42 U.S.C. 1395n(a)) is amended by inserting before 
‘‘For purposes of paragraph (2)(A),’’ the following new sen-
tence: ‘‘For purposes of documentation for physician certifi-
cation and recertification made under paragraph (2) on or 
after January 1, 2019, and made with respect to home 
health services furnished by a home health agency, in addi-
tion to using documentation in the medical record of the 
physician who so certifies or the medical record of the acute 
or post-acute care facility (in the case that home health 
services were furnished to an individual who was directly 
admitted to the home health agency from such a facility), 
the Secretary may use documentation in the medical record 
of the home health agency as supporting material, as appro-
priate to the case involved.’’. 
SEC. 51003. TECHNICAL AMENDMENTS TO PUBLIC LAW 114– 
10. 
(a) MIPS TRANSITION.—Section 1848 of the Social 
Security Act (42 U.S.C. 1395w–4) is amended— 
(1) in subsection (q)— 
(A) in paragraph (1)— 
(i) in subparagraph (B), by striking 
‘‘items and services’’ and inserting ‘‘covered 
professional services (as defined in sub-
section (k)(3)(A))’’; and
585 
† HR 1892 EAS2 
(ii) in subparagraph (C)(iv)— 
(I) by amending subclause (I) to 
read as follows: 
‘‘(I) The minimum number (as 
determined by the Secretary) of— 
‘‘(aa) for performance peri-
ods beginning before January 1, 
2018, individuals enrolled under 
this part who are treated by the 
eligible professional for the per-
formance period involved; and 
‘‘(bb) for performance periods 
beginning on or after January 1, 
2018, individuals enrolled under 
this part who are furnished cov-
ered professional services (as de-
fined in subsection (k)(3)(A)) by 
the eligible professional for the 
performance period involved.’’; 
(II) in subclause (II), by striking 
‘‘items and services’’ and inserting 
‘‘covered professional services (as de-
fined in subsection (k)(3)(A))’’; and 
(III) by amending subclause (III) 
to read as follows:
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† HR 1892 EAS2 
‘‘(III) The minimum amount (as 
determined by the Secretary) of— 
‘‘(aa) for performance peri-
ods beginning before January 1, 
2018, allowed charges billed by 
such professional under this part 
for such performance period; and 
‘‘(bb) for performance periods 
beginning on or after January 1, 
2018, allowed charges for covered 
professional services (as defined in 
subsection (k)(3)(A)) billed by 
such professional for such per-
formance period.’’; 
(B) in paragraph (5)(D)— 
(i) in clause (i)(I), by inserting ‘‘sub-
ject to clause (iii),’’ after ‘‘clauses (i) and 
(ii) of paragraph (2)(A),’’; and 
(ii) by adding at the end the following 
new clause: 
‘‘(iii) TRANSITION YEARS.—For each of 
the second, third, fourth, and fifth years for 
which the MIPS applies to payments, the 
performance score for the performance cat-
egory described in paragraph (2)(A)(ii)
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† HR 1892 EAS2 
shall not take into account the improvement 
of the professional involved.’’; 
(C) in paragraph (5)(E)— 
(i) in clause (i)(I)(bb)— 
(I) in the heading by striking 
‘‘FIRST
YEARS’’ 
and 
inserting 
‘‘FIRST 5 YEARS’’; and 
(II) by striking ‘‘the first and sec-
ond years’’ and inserting ‘‘each of the 
first through fifth years’’; 
(ii) in clause (i)(II)(bb)— 
(I) in the heading, by striking ‘‘2 
YEARS’’ and inserting ‘‘5 YEARS’’; and 
(II) by striking the second sen-
tence and inserting the following new 
sentences: ‘‘For each of the second, 
third, fourth, and fifth years for which 
the MIPS applies to payments, not less 
than 10 percent and not more than 30 
percent of such score shall be based on 
performance with respect to the cat-
egory described in clause (ii) of para-
graph (2)(A). Nothing in the previous 
sentence shall be construed, with re-
spect to a performance period for a
588 
† HR 1892 EAS2 
year described in the previous sentence, 
as preventing the Secretary from bas-
ing 30 percent of such score for such 
year with respect to the category de-
scribed in such clause (ii), if the Sec-
retary determines, based on informa-
tion posted under subsection (r)(2)(I) 
that sufficient resource use measures 
are ready for adoption for use under 
the performance category under para-
graph (2)(A)(ii) for such performance 
period.’’; 
(D) in paragraph (6)(D)— 
(i) in clause (i), in the second sentence, 
by striking ‘‘Such performance threshold’’ 
and inserting ‘‘Subject to clauses (iii) and 
(iv), such performance threshold’’; 
(ii) in clause (ii)— 
(I) in the first sentence, by insert-
ing ‘‘(beginning with 2019 and ending 
with 2024)’’ after ‘‘for each year of the 
MIPS’’; and 
(II) in the second sentence, by in-
serting ‘‘subject to clause (iii),’’ after 
‘‘For each such year,’’;
595 
† HR 1892 EAS2 
SEC. 51007. EXTENSION OF ENFORCEMENT INSTRUCTION 
ON SUPERVISION REQUIREMENTS FOR OUT-
PATIENT THERAPEUTIC SERVICES IN CRIT-
ICAL ACCESS AND SMALL RURAL HOSPITALS 
THROUGH 2017. 
Section 1 of Public Law 113–198, as amended by sec-
tion 1 of Public Law 114–112 and section 16004(a) of the 
21st Century Cures Act (Public Law 114–255), is amend-
ed— 
(1) in the section heading, by striking ‘‘2016’’ 
and inserting ‘‘2017’’; and 
(2) by striking ‘‘and 2016’’ and inserting ‘‘2016, 
and 2017’’. 
SEC. 51008. ALLOWING PHYSICIAN ASSISTANTS, NURSE 
PRACTITIONERS, AND CLINICAL NURSE SPE-
CIALISTS TO SUPERVISE CARDIAC, INTEN-
SIVE CARDIAC, AND PULMONARY REHABILI-
TATION PROGRAMS. 
(a) CARDIAC AND INTENSIVE CARDIAC REHABILITA-
TION PROGRAMS.—Section 1861(eee) of the Social Security 
Act (42 U.S.C. 1395x(eee)) is amended— 
(1) in paragraph (1)— 
(A) by striking ‘‘physician-supervised’’; and 
(B) by inserting ‘‘under the supervision of 
a physician (as defined in subsection (r)(1)) or 
a physician assistant, nurse practitioner, or