I 
112TH CONGRESS 
2D SESSION 
H. R. 5194 
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, to amend title III of the Public Health 
Service Act to extend discounts under the 340B program, and for other 
purposes. 
IN THE HOUSE OF REPRESENTATIVES 
APRIL 27, 2012 
Mrs. MCMORRIS RODGERS (for herself and Mr. THOMPSON of California) in-
troduced the following bill; which was referred to the Committee on En-
ergy and Commerce, and in addition to the Committee on Ways and 
Means, for a period to be subsequently determined by the Speaker, in 
each case for consideration of such provisions as fall within the jurisdic-
tion of the committee concerned 
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 pro-
gram, to amend title III of the Public Health Service 
Act to extend discounts under the 340B program, and 
for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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Sec. 201. Extension of discounts to inpatient drugs. 
Sec. 202. Prohibition against duplicate discounts for physician administered 
drugs. 
Sec. 203. Continued inclusion of orphan drugs in definition of covered out-
patient drugs; technical amendment. 
Sec. 204. Application of rules for determining provider-based status for certain 
entities. 
TITLE I—RURAL HOSPITAL AND 
PROVIDER EQUITY 
SEC. 101. SENSE OF THE CONGRESS. 
It is the sense of the Congress 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 com-
munities and such communities in an equitable and 
sustainable manner; and 
(4) stakeholders should work collectively to 
identify innovative policies that address the avail-
ability, delivery, and affordability of health care 
services in rural and frontier communities. 
SEC. 
102. 
FAIRNESS 
IN 
THE 
MEDICARE 
DISPROPOR-
TIONATE SHARE HOSPITAL (DSH) ADJUST-
MENT 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 pre-
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ceding sentence shall not apply to any hospital with re-
spect to discharges occurring on or after October 1, 2011, 
and before October 1, 2012.’’. 
SEC. 103. EXTENSION AND EXPANSION OF THE MEDICARE 
HOLD HARMLESS PROVISION UNDER THE 
PROSPECTIVE PAYMENT SYSTEM FOR HOS-
PITAL 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 striking 
‘‘March 1, 2012’’ and inserting ‘‘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 in 
the last 10 months of 2012’’; and 
(2) in subclause (III)— 
(A) in the first sentence— 
(i) by striking ‘‘2009, and before 
March 1, 2012, for which’’ and inserting 
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‘‘2009, and before January 1, 2013, for 
which’’; and 
(ii) by striking ‘‘85 percent’’ and in-
serting ‘‘the applicable percentage (as de-
termined under the second sentence of sub-
clause (II) for the year)’’; and 
(B) in the second sentence, by striking 
‘‘2010, and before March 1, 2012, the pre-
ceding’’ and inserting ‘‘2010, and before Janu-
ary 1, 2013, the preceding’’. 
SEC. 104. TEMPORARY IMPROVEMENTS TO THE MEDICARE 
INPATIENT 
HOSPITAL 
PAYMENT 
ADJUST-
MENT 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 (C)(i), by inserting ‘‘and 
2,000 discharges, respectively,’’ after ‘‘1,600 dis-
charges’’; and 
(2) 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 sen-
tence, the term ‘applicable number of dis-
charges’ means 1,600 discharges with respect to 
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discharges occurring in fiscal year 2011 and 
2,000 discharges with respect to discharges oc-
curring in fiscal year 2012’’. 
SEC. 105. EXTENSION OF MEDICARE WAGE INDEX RECLAS-
SIFICATIONS FOR CERTAIN HOSPITALS. 
(a) EXTENSION OF CORRECTION OF MID-YEAR RE-
CLASSIFICATION
EXPIRATION
FOR
CERTAIN
HOS-
PITALS.— 
(1) IN GENERAL.—In the case of a hospital de-
scribed in paragraph (2), the Secretary of Health 
and Human Services shall apply 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, Med-
icaid, and SCHIP Extension Act of 2007 (Public 
Law 110–173), section 124 of the Medicare Im-
provements 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), and section 102 of the Medi-
care and Medicaid Extenders Act of 2010 (Public 
Law 111–309), by substituting ‘‘September 30, 
2012’’ for ‘‘November 30, 2011’’. 
(2) HOSPITAL
DESCRIBED.—A hospital de-
scribed in this paragraph is— 
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(A) a hospital— 
(i) that is described in subsection (a) 
of such section 106; and 
(ii)(I) that is located in a rural area; 
and 
(II) for which the Secretary of Health 
and Human Services has determined the 
extension under this subsection to be ap-
propriate; 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 re-
classification extension under section 117(a)(2) 
of the Medicare, Medicaid, and SCHIP Exten-
sion Act of 2007 (Public Law 110–173). 
(b) NOT BUDGET NEUTRAL.—The provisions of this 
section shall not be effected in a budget-neutral manner. 
SEC. 106. EXTENSION OF MEDICARE REASONABLE COSTS 
PAYMENTS FOR CERTAIN CLINICAL DIAG-
NOSTIC 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–4), as amended by section 105 of division B of the 
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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 by striking ‘‘the 2-year period beginning 
on July 1, 2010’’ and inserting ‘‘the 30-month period be-
ginning on July 1, 2010’’. 
SEC. 107. 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 ar-
rangement with the hospital)’’ after ‘‘hospital’’; 
and 
(2) by striking the comma at the end of sub-
paragraph (B) and all that follows and inserting a 
period. 
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(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply to services furnished on or after 
January 1, 2012. 
SEC. 108. 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 January 1, 2012, and before 
January 1, 2013’’ after ‘‘2008’’. 
SEC. 109. EXTENSION OF FLOOR ON MEDICARE WORK GEO-
GRAPHIC ADJUSTMENT. 
Section 1848(e)(1)(E) of the Social Security Act (42 
U.S.C. 1395w–4(e)(1)(E)) is amended by striking ‘‘before 
March 1, 2012’’ and inserting ‘‘before January 1, 2013’’. 
SEC. 110. IMPROVING CARE PLANNING FOR MEDICARE 
HOME HEALTH SERVICES. 
(a) PART A PROVISIONS.—Section 1814(a) of the So-
cial 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 clin-
ical nurse specialist who is working in collabo-
ration with a physician in accordance with 
State law, a certified nurse-midwife (as defined 
in section 1861(gg)) as authorized by State law, 
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or a physician assistant (as defined in section 
1861(aa)(5)) under the supervision of a physi-
cian’’ after ‘‘1866(j)’’; and 
(B) in subparagraph (C)— 
(i) by inserting ‘‘, a nurse practi-
tioner, a clinical nurse specialist, a cer-
tified nurse-midwife, or a physician assist-
ant (as the case may be)’’ after ‘‘physi-
cian’’ 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 en-
counter’’ and inserting ‘‘, and, in the case 
of a certification made by a physician after 
January 1, 2010, or by a nurse practi-
tioner, clinical nurse specialist, certified 
nurse-midwife, or physician assistant (as 
the case may be) after January 1, 2012, 
prior to making such certification the phy-
sician, nurse practitioner, clinical nurse 
specialist, certified nurse-midwife, or physi-
cian assistant must document that the 
physician, nurse practitioner, clinical nurse 
specialist, certified nurse-midwife, or physi-
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cian assistant has had a face-to-face en-
counter’’; 
(2) in the second sentence, by inserting ‘‘cer-
tified nurse-midwife,’’ after ‘‘clinical nurse spe-
cialist,’’; 
(3) in the third sentence— 
(A) by striking ‘‘physician certification’’ 
and inserting ‘‘certification’’; 
(B) by inserting ‘‘(or on January 1, 2012, 
in the case of regulations to implement the 
amendments made by section 11 of the Rural 
Hospital and Provider Equity and 340B Im-
provement Act of 2012)’’ after ‘‘1981’’; and 
(C) by striking ‘‘a physician who’’ and in-
serting ‘‘a physician, nurse practitioner, clinical 
nurse specialist, certified nurse-midwife, or phy-
sician assistant who’’; and 
(4) in the fourth 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 So-
cial 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 clin-
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ical nurse specialist (as those terms are defined 
in section 1861(aa)(5)) who is working in col-
laboration 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 physi-
cian’’ 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 as-
sistant (as the case may be)’’ after ‘‘physi-
cian’’; and 
(ii) in clause (iv), by striking ‘‘after 
January 1, 2010’’ and all that follows 
through ‘‘face-to-face encounter’’ and in-
serting ‘‘made by a physician after Janu-
ary 1, 2010, or by a nurse practitioner, 
clinical nurse specialist, certified nurse- 
midwife, or physician assistant (as the case 
may be) after January 1, 2012, prior to 
making such certification the physician, 
nurse practitioner, clinical nurse specialist, 
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certified nurse-midwife, or physician assist-
ant must document that the physician, 
nurse practitioner, clinical nurse specialist, 
certified nurse-midwife, or physician assist-
ant 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, 2012, 
in the case of regulations to implement the 
amendments made by section 11 of the Rural 
Hospital and Provider Equity and 340B Im-
provement Act of 2012)’’ after ‘‘1981’’; and 
(C) by striking ‘‘a physician who’’ and in-
serting ‘‘a physician, nurse practitioner, clinical 
nurse specialist, certified nurse-midwife, or phy-
sician 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.— 
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(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 sec-
tion 1861(gg)), or a physician assistant (as 
defined in subsection (aa)(5))’’ after ‘‘phy-
sician’’ the first place it appears; and 
(ii) by inserting ‘‘, a nurse practi-
tioner, a clinical nurse specialist, a cer-
tified nurse-midwife, or a physician assist-
ant’’ 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 assist-
ant’’ after ‘‘physician’’. 
(2) 
HOME
HEALTH
AGENCY.—Section 
1861(o)(2) of the Social Security Act (42 U.S.C. 
1395x(o)(2)) is amended— 
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(A) by inserting ‘‘, nurse practitioners or 
clinical nurse specialists (as those terms are de-
fined in subsection (aa)(5)), certified nurse-mid-
wives (as defined in section 1861(gg)), or physi-
cian assistants (as defined in subsection 
(aa)(5))’’ after ‘‘physicians’’; and 
(B) by inserting ‘‘, nurse practitioner, clin-
ical 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 
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(B) in paragraph (2)— 
(i) in the heading, by striking ‘‘PHY-
SICIAN
CERTIFICATION’’ 
and 
inserting 
‘‘RULE OF CONSTRUCTION REGARDING RE-
QUIREMENT 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, 2012. 
SEC. 111. 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 2012)’’ 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 2012, at $101 per visit; and 
‘‘(4) in a subsequent year, at the limit estab-
lished under this subsection for the previous year in-
creased by the percentage increase in the MEI (as 
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so defined) applicable to primary care services (as so 
defined) furnished as of the first day of that year.’’. 
SEC. 112. 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) and section 3131(c) of the Patient Pro-
tection and Affordable Care Act (Public Law 111–148; 
124 Stat. 428), is amended by striking ‘‘2016, 3 percent’’ 
and inserting ‘‘2011, and episodes and visits ending on 
or after January 1, 2013, and before January 1, 2016, 
3 percent’’. 
SEC. 113. EXTENSION OF INCREASED MEDICARE PAYMENTS 
FOR RURAL GROUND AMBULANCE SERVICES. 
(a) IN GENERAL.—Section 1834(l)(13)(A) of the So-
cial Security Act (42 U.S.C. 1395m(l)(13)(A)) is amend-
ed— 
(1) in the matter preceding clause (i)— 
(A) by striking ‘‘2007, and for’’ and in-
serting ‘‘2007, for’’; and 
(B) by inserting ‘‘, and for such services 
described in clause (i) furnished on or after 
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March 1, 2012, and before January 1, 2013’’ 
after ‘‘2012’’; and 
(2) in clause (i), by inserting ‘‘, or 5 percent if 
such service is furnished on or after March 1, 2012, 
and before January 1, 2013’’ after ‘‘2012’’. 
(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 ‘‘March 1, 
2012’’ and inserting ‘‘January 1, 2013’’. 
SEC. 114. EXTENSION OF PAYMENT FOR TECHNICAL COM-
PONENT OF CERTAIN PHYSICIAN PATHOL-
OGY SERVICES. 
Section 542(c) of the Medicare, Medicaid, and 
SCHIP Benefits Improvement and Protection Act of 2000 
(as enacted into law by section 1(a)(6) of Public Law 106– 
554), as amended by section 732 of the Medicare Prescrip-
tion Drug, Improvement, and Modernization Act of 2003 
(42 U.S.C. 1395w–4 note), section 104 of division B of 
the Tax Relief and Health Care Act of 2006 (42 U.S.C. 
1395w–4 note), section 104 of the Medicare, Medicaid, 
and SCHIP Extension Act of 2007 (Public Law 110– 
173), section 136 of the Medicare Improvements for Pa-
tients and Providers Act of 2008 (Public Law 110–275), 
section 3104 of the Patient Protection and Affordable 
Care Act (Public Law 111–148), section 105 of the Medi-
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care and Medicaid Extenders Act of 2010 (Public Law 
111–309), and section 305 of the Temporary Payroll Tax 
Cut Continuation Act of 2011 (Public Law 112–78) is 
amended by striking ‘‘the first two months of’’. 
SEC. 115. 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 Sec-
retary of Health and Human Services shall, in consulta-
tion with representatives of States, physicians, health care 
practitioners, and patient advocates, encourage and facili-
tate the adoption of provisions allowing for multistate 
practitioner practice across State lines. 
(b) DEFINITIONS.—In subsection (a): 
(1) TELEHEALTH
SERVICE.—The term ‘‘tele-
health service’’ has the meaning given that term in 
subparagraph (F) of section 1834(m)(4) of the So-
cial 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), re-
spectively, of such section. 
(3) MEDICARE PROGRAM.—The term ‘‘Medicare 
program’’ means the program of health insurance 
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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. 116. MEDICARE PART A PAYMENT FOR ANESTHESIOL-
OGIST SERVICES IN CERTAIN RURAL HOS-
PITALS BASED ON CRNA PASS-THROUGH 
RULES. 
(a) IN GENERAL.—Section 1814 of the Social Secu-
rity 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 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, (relating to 
payment on a reasonable cost, pass-through basis) for cer-
tified registered nurse anesthetist services furnished by a 
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certified registered nurse anesthetist in a hospital de-
scribed in such section 9320(k). 
‘‘(2) No payment shall be made under any other pro-
vision of this title for physicians’ services for which pay-
ment 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 added and 
amended, except that— 
‘‘(A) any reference in such section to a ‘cer-
tified registered nurse anesthetist’ or an ‘anesthetist’ 
is deemed a reference to a ‘physician who is an anes-
thesiologist’ or an ‘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. 
VerDate Mar 15 2010 
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