II 114th CONGRESS 2d Session S. 3435 IN THE SENATE OF THE UNITED STATES September 28, 2016 Mr. Roberts (for himself, Mr. Franken , Mr. Barrasso , and Ms. Heitkamp ) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend title XVIII of the Social Security Act to protect and preserve access of Medicare beneficiaries in rural areas to health care providers under the Medicare program, and for other purposes.

1. 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. 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. 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. . 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, . 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. . 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 . 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. 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. 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. 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: 1603. Capital infrastructure revolving loan program (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) . 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 . 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 . 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. 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. 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. . 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. 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 . 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: (iii) Marriage and Family Therapist Services; Marriage and Family Therapist; Mental Health Counselor Services; Mental Health Counselor (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. 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. ). 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: (m) Anesthesiologist Services Provided in Certain Rural Hospitals (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. 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. . 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. . 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. 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: 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. . 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. 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 . 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.