1192
(2) EFFECTIVE
DATE.—The amendment
made by paragraph (1) shall take effect on Jan-
uary 1, 1998.
(c) WAIVER OF CERTAIN STAFFING REQUIREMENTS
LIMITED TO CLINICS IN PROGRAM.—
(1) IN GENERAL.—Section 1861(aa)(7)(B) (42
U.S.C. 1395x(aa)(7)(B)) is amended by inserting
before the period at the end the following: ‘‘, or if
the facility has not yet been determined to meet the
requirements (including subparagraph (J) of the
first sentence of paragraph (2)) of a rural health
clinic’’.
(2) EFFECTIVE DATE.—The amendment made
by paragraph (1) applies to waiver requests made
after 1997.
(d) REFINEMENT
OF SHORTAGE AREA REQUIRE-
MENTS.—
(1) DESIGNATION REVIEWED TRIENNIALLY.—
Section 1861(aa)(2) (42 U.S.C. 1395x(aa)(2)) is
amended in the second sentence, in the matter in
clause (i) preceding subclause (I)—
(A) by striking ‘‘and that is designated’’
and inserting ‘‘and that, within the previous
three-year period, has been designated’’; and
1193
(B) by striking ‘‘or that is designated’’ and
inserting ‘‘or designated’’.
(2) AREA MUST HAVE SHORTAGE OF HEALTH
CARE
PRACTITIONERS.—Section 1861(aa)(2) (42
U.S.C. 1395x(aa)(2)), as amended by paragraph (1),
is further amended in the second sentence, in the
matter in clause (i) preceding subclause (I)—
(A) by striking the comma after ‘‘personal
health services’’; and
(B) by inserting ‘‘and in which there are
insufficient numbers of needed health care prac-
titioners (as determined by the Secretary),’’
after ‘‘Bureau of the Census)’’.
(3) PREVIOUSLY QUALIFYING CLINICS GRAND-
FATHERED ONLY TO PREVENT SHORTAGE.—Section
1861(aa)(2) (42 U.S.C. 1395x(aa)(2)) is amended in
the third sentence by inserting before the period ‘‘if
it is determined, in accordance with criteria estab-
lished by the Secretary in regulations, to be essential
to the delivery of primary care services that would
otherwise be unavailable in the geographic area
served by the clinic’’.
(4) EFFECTIVE DATES; IMPLEMENTING REGU-
LATIONS.—
1194
(A) IN
GENERAL.—Except as otherwise
provided, the amendments made by the preced-
ing paragraphs take effect on January 1 of the
first calendar year beginning at least one month
after enactment of this Act.
(B) CURRENT RURAL HEALTH CLINICS.—
The amendments made by the preceding para-
graphs take effect, with respect to entities that
are rural health clinics under title XVIII of the
Social Security Act on the date of enactment of
this Act, on January 1 of the second calendar
year following the calendar year specified in
subparagraph (A).
(C) GRANDFATHERED CLINICS.—
(i) IN
GENERAL.—The amendment
made by paragraph (3) shall take effect on
the effective date of regulations issued by
the Secretary under clause (ii).
(ii) REGULATIONS.—The Secretary
shall issue final regulations implementing
paragraph (3) that shall take effect no
later than January 1 of the third calendar
year beginning at least one month after en-
actment of this Act.
1195
SEC. 10619. INCREASED MEDICARE REIMBURSEMENT FOR
NURSE 
PRACTITIONERS 
AND 
CLINICAL
NURSE SPECIALISTS.
(a) REMOVAL OF RESTRICTIONS ON SETTINGS.—
(1) IN
GENERAL.—Clause (ii) of section
1861(s)(2)(K) 
(42 
U.S.C. 
1395x(s)(2)(K)) 
is
amended to read as follows:
‘‘(ii) services which would be physicians’ serv-
ices if furnished by a physician (as defined in sub-
section (r)(1)) and which are performed by a nurse
practitioner or clinical nurse specialist (as defined in
subsection (aa)(5)) working in collaboration (as de-
fined in subsection (aa)(6)) with a physician (as de-
fined in subsection (r)(1)) which the nurse practi-
tioner or clinical nurse specialist is legally authorized
to perform by the State in which the services are
performed, and such services and supplies furnished
as an incident to such services as would be covered
under subparagraph (A) if furnished incident to a
physician’s professional service, but only if no facil-
ity or other provider charges or is paid any amounts
with respect to the furnishing of such services;’’.
(2) CONFORMING AMENDMENTS.—(A) Section
1861(s)(2)(K) 
of 
such 
Act 
(42 
U.S.C.
1395x(s)(2)(K)) is further amended—
1196
(i) in clause (i), by inserting ‘‘and such
services and supplies furnished as incident to
such services as would be covered under sub-
paragraph (A) if furnished incident to a physi-
cian’s professional service,’’ after ‘‘are per-
formed,’’; and
(ii) by striking clauses (iii) and (iv).
(B) 
Section 
1861(b)(4) 
(42 
U.S.C.
1395x(b)(4)) is amended by striking ‘‘clauses (i) or
(iii) of subsection (s)(2)(K)’’ and inserting ‘‘sub-
section (s)(2)(K)’’.
(C) 
Section 
1862(a)(14) 
(42 
U.S.C.
1395y(a)(14)) is amended by striking ‘‘section
1861(s)(2)(K)(i) or 1861(s)(2)(K)(iii)’’ and insert-
ing ‘‘section 1861(s)(2)(K)’’.
(D) 
Section 
1866(a)(1)(H) 
(42 
U.S.C.
1395cc(a)(1)(H)) is amended by striking ‘‘section
1861(s)(2)(K)(i) or 1861(s)(2)(K)(iii)’’ and insert-
ing ‘‘section 1861(s)(2)(K)’’.
(E) 
Section 
1888(e)(2)(A)(ii) 
(42 
U.S.C.
1395yy(e)(2)(A)(ii)), as added by section 10401(a),
is amended by striking ‘‘through (iii)’’ and inserting
‘‘and (ii)’’.
(b) INCREASED PAYMENT.—
1197
(1) FEE SCHEDULE AMOUNT.—Clause (O) of
section 1833(a)(1) (42 U.S.C. 1395l(a)(1)) is
amended to read as follows: ‘‘(O) with respect to
services described in section 1861(s)(2)(K)(ii) (relat-
ing to nurse practitioner or clinical nurse specialist
services), the amounts paid shall be equal to 80 per-
cent of (i) the lesser of the actual charge or 85 per-
cent of the fee schedule amount provided under sec-
tion 1848, or (ii) in the case of services as an assist-
ant at surgery, the lesser of the actual charge or 85
percent of the amount that would otherwise be rec-
ognized if performed by a physician who is serving
as an assistant at surgery; and’’.
(2) CONFORMING AMENDMENTS.—(A) Section
1833(r) (42 U.S.C. 1395l(r)) is amended—
(i) in paragraph (1), by striking ‘‘section
1861(s)(2)(K)(iii) (relating to nurse practi-
tioner or clinical nurse specialist services pro-
vided in a rural area)’’ and inserting ‘‘section
1861(s)(2)(K)(ii) (relating to nurse practitioner
or clinical nurse specialist services)’’;
(ii) by striking paragraph (2);
(iii) in paragraph (3), by striking ‘‘section
1861(s)(2)(K)(iii)’’ 
and 
inserting 
‘‘section
1861(s)(2)(K)(ii)’’; and
1198
(iv) by redesignating paragraph (3) as
paragraph (2).
(B) 
Section 
1842(b)(12)(A) 
(42 
U.S.C.
1395u(b)(12)(A)) is amended, in the matter preced-
ing clause (i), by striking ‘‘clauses (i), (ii), or (iv) of
section 1861(s)(2)(K) (relating to a physician assist-
ants and nurse practitioners)’’ and inserting ‘‘sec-
tion 1861(s)(2)(K)(i) (relating to physician assist-
ants),’’.
(c) DIRECT PAYMENT FOR NURSE PRACTITIONERS
AND CLINICAL NURSE SPECIALISTS.—
(1) IN
GENERAL.—Section 1832(a)(2)(B)(iv)
(42 U.S.C. 1395k(a)(2)(B)(iv)) is amended by strik-
ing ‘‘provided in a rural area (as defined in section
1886(d)(2)(D))’’ and inserting ‘‘but only if no facil-
ity or other provider charges or is paid any amounts
with respect to the furnishing of such services’’.
(2) 
CONFORMING
AMENDMENT.—Section
1842(b)(6)(C) 
(42 
U.S.C. 
1395u(b)(6)(C)) 
is
amended—
(A) by striking ‘‘clauses (i), (ii), or (iv)’’
and inserting ‘‘clause (i)’’; and
(B) by striking ‘‘or nurse practitioner’’.
1199
(d) DEFINITION OF CLINICAL NURSE SPECIALIST
CLARIFIED.— 
Section 
1861(aa)(5) 
(42 
U.S.C.
1395x(aa)(5)) is amended—
(1) by inserting ‘‘(A)’’ after ‘‘(5)’’;
(2) by striking ‘‘The term ‘physician assistant’
’’ and all that follows through ‘‘who performs’’ and
inserting ‘‘The term ‘physician assistant’ and the
term ‘nurse practitioner’ mean, for purposes of this
title, a physician assistant or nurse practitioner who
performs’’; and
(3) by adding at the end the following new sub-
paragraph:
‘‘(B) The term ‘clinical nurse specialist’ means, for
purposes of this title, an individual who—
‘‘(i) is a registered nurse and is licensed to
practice nursing in the State in which the clinical
nurse specialist services are performed; and
‘‘(ii) holds a master’s degree in a defined clini-
cal area of nursing from an accredited educational
institution.’’.
(e) EFFECTIVE DATE.—The amendments made by
this section shall apply with respect to services furnished
and supplies provided on and after January 1, 1998.
1200
SEC. 10620. INCREASED MEDICARE REIMBURSEMENT FOR
PHYSICIAN ASSISTANTS.
(a) REMOVAL OF RESTRICTION ON SETTINGS.—Sec-
tion 1861(s)(2)(K)(i) (42 U.S.C. 1395x(s)(2)(K)(i)) is
amended—
(1) by striking ‘‘(I) in a hospital’’ and all that
follows through ‘‘shortage area,’’, and
(2) by adding at the end the following: ‘‘but
only if no facility or other provider charges or is
paid any amounts with respect to the furnishing of
such services,’’.
(b) INCREASED PAYMENT.—Paragraph (12) of sec-
tion 1842(b) (42 U.S.C. 1395u(b)), as amended by section
10619(b)(2)(B), is amended to read as follows:
‘‘(12) With respect to services described in section
1861(s)(2)(K)(i)—
‘‘(A) payment under this part may only be
made on an assignment-related basis; and
‘‘(B) the amounts paid under this part shall be
equal to 80 percent of (i) the lesser of the actual
charge or 85 percent of the fee schedule amount
provided under section 1848 for the same service
provided by a physician who is not a specialist; or
(ii) in the case of services as an assistant at surgery,
the lesser of the actual charge or 85 percent of the
amount that would otherwise be recognized if per-
1201
formed by a physician who is serving as an assistant
at surgery.’’.
(c) REMOVAL
OF RESTRICTION
ON EMPLOYMENT
RELATIONSHIP.—Section 
1842(b)(6) 
(42 
U.S.C.
1395u(b)(6)) is amended by adding at the end the follow-
ing new sentence: ‘‘For purposes of clause (C) of the first
sentence of this paragraph, an employment relationship
may include any independent contractor arrangement, and
employer status shall be determined in accordance with
the law of the State in which the services described in such
clause are performed.’’.
(d) EFFECTIVE DATE.—The amendments made by
this section shall apply with respect to services furnished
and supplies provided on and after January 1, 1998.
SEC. 10621. RENAL DIALYSIS-RELATED SERVICES.
(a) AUDITING OF COST REPORTS.—The Secretary
shall audit a sample of cost reports of renal dialysis pro-
viders for 1995 and for each third year thereafter.
(b) IMPLEMENTATION OF QUALITY STANDARDS.—
The Secretary of Health and Human Services shall de-
velop and implement, by not later than January 1, 1999,
a method to measure and report quality of renal dialysis
services provided under the medicare program under title
XVIII of the Social Security Act in order to reduce pay-
ments for inappropriate or low quality care.
1202
CHAPTER 3—PART B PREMIUM
SEC. 10631. PART B PREMIUM.
(a) IN GENERAL.—The first, second and third sen-
tences of section 1839(a)(3) (42 U.S.C. 1395r(a)(3)) are
amended to read as follows: ‘‘The Secretary, during Sep-
tember of each year, shall determine and promulgate a
monthly premium rate for the succeeding calendar year.
That monthly premium rate shall be equal to 50 percent
of the monthly actuarial rate for enrollees age 65 and over,
determined according to paragraph (1), for that succeed-
ing calendar year.’’.
(b) CONFORMING AND TECHNICAL AMENDMENTS.—
(1) SECTION 1839.—Section 1839 (42 U.S.C.
1395r) is amended—
(A) in subsection (a)(2), by striking ‘‘(b)
and (e)’’ and inserting ‘‘(b), (c), and (f)’’,
(B) in the last sentence of subsection
(a)(3)—
(i) by inserting ‘‘rate’’ after ‘‘pre-
mium’’, and
(ii) by striking ‘‘and the derivation of
the dollar amounts specified in this para-
graph’’,
(C) by striking subsection (e), and