II 118th CONGRESS 1st Session S. 1869 IN THE SENATE OF THE UNITED STATES June 7, 2023 Mr. Braun (for himself, Ms. Hassan , and Mr. Kennedy ) 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 and title XXVII of the Public Health Service Act to ensure fair billing practice for items and services furnished by off-campus hospital locations, to amend such title XVIII to provide for payments for graduate nursing education costs, and for other purposes.

1. Short title This Act may be cited as the Site-based Invoicing and Transparency Enhancement Act or the SITE Act . 2. Ensuring fair billing practice for items and services furnished by off-campus hospital locations (a) Promoting Medicare site-Neutral payments Section 1833(t)(21) of the Social Security Act ( 42 U.S.C. 1395l(t)(21) ) is amended— (1) by redesignating subparagraph (E) as subparagraph (G); and (2) by inserting after subparagraph (D) the following new subparagraphs: (E) Sunset of certain exceptions The provisions of clauses (ii) and (iv) of subparagraph (B) shall not apply with respect to applicable items and services furnished on or after January 1, 2025. (F) Special payment rule for non-applicable items and services furnished at certain off-campus dedicated emergency departments (i) In general In the case of covered OPD services furnished by an applicable dedicated emergency department during 2025 or a subsequent year, the payment amount for such service that would otherwise be determined under this subsection (without regard to the application of this subparagraph) for such year shall be reduced by 30 percent. (ii) Applicable dedicated emergency department In clause (i), the term applicable dedicated emergency department means a dedicated emergency department (as defined in section 489.24(b) of title 42 of the Code of Federal Regulations) that— (I) is an off-campus outpatient department of a provider (as defined in subparagraph (B)); and (II) is located 6 or fewer miles from another hospital, critical access hospital, or rural emergency hospital, including the parent hospital of such emergency department. . (b) Ensuring separate NPIs for off-Campus outpatient departments of a provider (1) In general Section 1173(b) of the Social Security Act ( 42 U.S.C. 1320d–2(b) ) is amended by adding at the end the following new paragraph: (3) Ensuring separate NPIs for off-campus outpatient departments of a provider The standards specified under paragraph (1) shall ensure that, not later than January 1, 2025, each off-campus outpatient department of a provider (as defined in section 1833(t)(21)(B)) is assigned a separate unique health identifier from such provider. . (2) Treatment of certain departments as subparts of a hospital Not later than January 1, 2025, the Secretary of Health and Human Services shall revise sections 162.408 and 162.410 of title 45, Code of Federal Regulations, to ensure that each off-campus outpatient department of a provider (as defined in section 1833(t)(21)(B) of the Social Security Act ( 42 U.S.C. 1395l(t)(21)(B) )) is treated as a subpart (as described in such sections) of such provider and assigned a unique health identifier pursuant to section 1173(b)(3) of such Act (as added by paragraph (1)). (c) Billing requirements for off-Campus outpatient departments of a provider (1) Medicare Section 1866(a)(1) of the Social Security Act ( 42 U.S.C. 1395cc(a)(1) ) is amended— (A) in subparagraph (X), by striking and at the end; (B) in subparagraph (Y)(ii)(V), by striking the period and inserting , and ; and (C) by inserting after subparagraph (Y) the following new subparagraph: (Z) in the case of a hospital with an off-campus outpatient department of a provider (as defined in section 1833(t)(21)(B)), with respect to items and services furnished at such department of a provider on or after January 1, 2025, to include in any claim form submitted under this title (including under part C of this title) for such items and services the unique health identifier established for such department of a provider pursuant to section 1173(b)(3). . (2) Other providers Part E of title XXVII of the Public Health Service Act ( 42 U.S.C. 300gg–131 et seq. ) is amended by adding at the end the following new section: 2799B–10. Billing requirements for off-campus departments of a provider or facility A health care provider or facility may not, with respect to items and services furnished to an individual at an off-campus outpatient department of a provider (as defined in section 1833(t)(21)(B) of the Social Security Act) on or after January 1, 2025, submit a claim for such items and services to a group health plan or health insurance issuer, and may not bill such an individual or hold such individual liable for such items and services, unless such items and services are billed— (1) using the separate unique health identifier established for such department pursuant to section 1173(b)(3) of such Act; and (2) on a HIPAA X12 837P transaction form or CMS 1500 form (or a successor transaction or form). . (3) Effective date The amendment made by paragraph (1) shall apply with respect to claims submitted for items and services furnished on or after January 1, 2025. 3. Payments for graduate nursing education costs (a) In general Title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ) is amended by adding at the end the following new section: 1899C. Payments for graduate nursing education costs (a) In general The Secretary shall provide for payments for qualified training costs in accordance with this section. Such payments shall be made from the Federal Supplementary Medical Insurance Trust Fund under section 1841. (b) Establishment of Hub structure (1) Application An eligible hospital seeking to operate as a Graduate Nursing Education Hub (in this section referred to as a Hub ) shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may specify. (2) Selection of eligible hospitals to operate as Hub (A) Establishment of regions The Secretary shall establish regions for Hubs based on hospital referral regions. (B) Selection of eligible hospitals For each hospital referral region, the Secretary shall select not more than one eligible hospital to operate as a Hub. (C) Limitation An eligible hospital may not be selected to operate, or participate as an eligible partner of, more than one Hub under this section. (D) Adjacent regions An eligible hospital may be selected to operate as a Hub for one or more adjacent hospital referral regions if no other qualifying eligible hospital submits an application for such regions, in which case the eligible hospital shall operate as a single Hub for such regions. (E) Multiple applications If more than one eligible hospital submits an application to operate as a Hub for a hospital referral region, the Secretary shall consider each application submitted, giving special consideration to the following: (i) The application of the eligible hospital that includes the greatest number of applicable schools of nursing that have an advanced practice registered nurse education program in the region (or in an adjacent region if an eligible hospital has not been selected to operate as a Hub for such region and the eligible hospital is submitting an application to operate as a single Hub for both regions). (ii) The application of the eligible hospital that includes the greatest number of advanced practice registered nurses that have graduated from participating applicable schools of nursing over the preceding 3 years. (c) Hub requirements (1) Contracts Each Hub selected pursuant to subsection (b)(2) must enter into a written agreement with each eligible partner of the Hub that meets contents and terms, as determined by the Secretary, and sets out, at a minimum, the following: (A) Partner Obligations The obligations of the eligible partner with respect to the provision of qualified training. (B) Reimbursement The obligation of the Hub to reimburse the eligible partner (in a timely manner as the Secretary may specify) for the costs of qualified training for which payment is made under this section that are attributable to such partner. (C) Governance Structure A governance structure that includes the Hub and one or more applicable schools of nursing in the leadership and an oversight process that is developed and approved by the Hub, participating applicable schools of nursing, and other Hub partners, in accordance with requirements established by the Secretary. (D) Coordination The maintenance of an adequate system for coordination of clinical education sites and preceptors. The Secretary may specify standards for such system. (E) Preceptor training A system for the Hub to provide at least 4 hours of preceptor training to each preceptor each year. (F) Public health needs A process for taking into consideration local, State, and regional workforce needs to ensure public health. (d) Payments (1) Amount of payment The amount of payment to a Hub under this section for qualified training costs during a year shall be equal to the product of— (A) the annual per student payment amount determined under paragraph (2) for the Hub for the year; and (B) the total number of positions distributed to the Hub under subsection (f), as determined by the Secretary. (2) Determination of Hub-specific annual per student payment amount The Secretary shall determine, for each Hub, an annual per student payment amount for each year (beginning with 2026). Such amount shall be equal to the unadjusted per student amount determined under paragraph (3), as adjusted for geographic variation in wages in a budget neutral manner, as determined appropriate by the Secretary. (3) Unadjusted per student amount The unadjusted per student amount determined under this paragraph for a year is equal to the product of— (A) 750 hours; and (B) the median hourly wage for a nurse practitioner in the United States, according to the Occupational Employment and Wage Statistics of the Bureau of Labor Statistics for the most recent year for which such data is available (or an appropriate successor measure), increased or decreased by the percentage change in the consumer price index for all urban consumers (all items; United States city average) from June of the most recent year for which such data is available to the June preceding the year involved. (4) Permissible uses of payment A Hub may use payments provided under this section only for payment of the costs of qualified training. (e) Number of training positions available The maximum number of positions for which payment made be made under this section for a year shall be equal to— (1) for each of 2026 and 2027, 10,000 advanced practice registered nurse students; (2) for each of 2028 and 2029, 15,000 advanced practice registered nurse students; (3) for each of 2030 and 2031: 20,000 advanced practice registered nurse students; and (4) for 2032 and subsequent years, the greater of— (A) 20,000 advanced practice registered nurse students; or (B) the number of advanced practice registered nurse students needed to ensure the ratio of such students to the number of beneficiaries under the program under this title, the Medicaid program under title XIX, and the CHIP program under title XXI during the year is the same as such ratio for 2031. (f) Distribution of training positions (1) In general (A) Distribution The Secretary shall distribute the applicable percent (as defined in subparagraph (B)) of the total number of positions available for distribution under subsection (e) for a year as follows: (i) Each Hub shall receive a minimum number of positions, as determined by the Secretary. (ii) Any remaining positions available for distribution under this subparagraph shall be distributed to Hubs based on the following factors: (I) The number of advanced practice registered nurses that have graduated from participating applicable schools of nursing over the preceding 3 years. (II) The share of the relevant hospital referral region that is located in an area designated as a health professional shortage area under section 332(a)(1)(A) of the Public Health Service Act, as determined by the Secretary. (III) The share of the relevant hospital referral region that is located in a frontier State (as defined in section 1886(d)(3)(E)(iii)(II)). (IV) The share of the relevant hospital referral region that is located in a rural area (as defined in section 1886(d)(2)(D)). (V) Other factors determined appropriate by the Secretary. (B) Applicable percent defined For purposes of subparagraph (A), the term applicable percent means— (i) for 2026 and 2027, 100 percent; (ii) for 2028 and 2029, 95 percent; and (iii) for 2030 and each subsequent year, 90 percent. (2) Testing new training models (A) In general The Secretary shall distribute the applicable percent (as defined in subparagraph (B)) of the total number of positions available for distribution under this subsection for a year to test new models of training advanced practice registered nurses and other health care workers or account for different workforce needs (for example, a shortage of certified nurse-midwives or community health workers). (B) Applicable percent defined For purposes of subparagraph (A), the term applicable percent means— (i) for 2026 and 2027, 0 percent; (ii) for 2028 and 2029, 5 percent; and (iii) for 2030 and each subsequent year, 10 percent. (3) Redistribution The Secretary shall develop a process for redistributing— (A) unused positions; and (B) positions from terminated or closed Hubs. (g) Miscellaneous (1) Waiver authority The Secretary may waive such requirements of title XI and this title as may be necessary to carry out this section. (2) Administration Chapter 35 of title 44, United States Code, shall not apply to the implementation of this section. (3) Judicial review There shall be no administrative or judicial review under section 1869, 1878, or otherwise, with respect to determinations made under subsection (d) or subsection (f). (4) No effect on other payments for medical education costs Nothing in this section shall affect payments under subsection (d)(5)(B), (h), or (l)(2)(B) of section 1886. (5) Implementation funding For purposes of carrying out this section, there are appropriated, out of amounts in the Treasury not otherwise appropriated, to the Centers for Medicare & Medicaid Services Program Management Account for fiscal year 2024, $100,000,000, to remain available until expended. (6) Supplement not supplant Payments under this section in any given year shall supplement, not supplant, other Federal funds that have been made available in the year for advanced practice registered nurse clinical education or training. (h) Definitions In this section: (1) Advanced practice registered nurse The term advanced practice registered nurse includes the following: (A) A clinical nurse specialist (as defined in subsection (aa)(5) of section 1861). (B) A nurse practitioner (as defined in such subsection). (C) A certified registered nurse anesthetist (as defined in subsection (bb)(2) of such section). (D) A certified nurse-midwife (as defined in subsection (gg)(2) of such section). (2) Ambulatory care setting The term ambulatory care setting includes a Federally qualified health center (as defined in section 1861(aa)(4)), a rural health clinic (as defined in section 1861(aa)(4)), a nurse-managed clinic, an ambulatory practice, a behavioral health clinic (including a clinic certified as a certified community behavioral health clinic pursuant to section 223 of the Protecting Access to Medicare Act of 2014) or other behavioral health setting (as determined appropriate by the Secretary), a physician or practitioner office, a school, a skilled nursing facility or nursing facility (as defined in section 1919(a)), a hospice program, a long-term care facility, and any other setting specified by the Secretary. (3) Applicable school of nursing The term applicable school of nursing means an accredited school of nursing (as defined in section 801 of the Public Health Service Act). (4) Eligible hospital The term eligible hospital means a hospital or a critical access hospital that has a written agreement described in subsection (c)(1) in place with— (A) at least two applicable schools of nursing (or at least one applicable school of nursing if there is only one applicable school of nursing within the hospital referral region); and (B) at least one ambulatory care setting that is not owned or operated by a Hub operated by the hospital or critical access hospital. (5) Eligible partner (A) In general The term eligible partner means— (i) an applicable school of nursing that has an advanced practice registered nurse education program; (ii) an entity or practitioner that is a participating provider under this title or a State plan under title XIX (or a waiver of such plan); and (iii) any other entity determined appropriate by the Secretary. (B) Limitation An applicable school of nursing, entity, or practitioner described in subparagraph (A) may not participate as an eligible partner of more than one Hub under this section. (6) Qualified training (A) In general The term qualified training means training— (i) that provides an advanced practice registered nurse with the clinical skills necessary to provide primary care, behavioral health care, obstetric care, preventive care, transitional care, chronic care management, and other services appropriate for individuals entitled to, or enrolled for, benefits under part A, or enrolled under part B; and (ii) subject to subparagraph (B), at least a third of which is provided in an ambulatory care setting that is not owned or operated by a Hub. (B) Waiver of requirement for eligible hospitals located in rural or medically undeserved areas The Secretary may waive the requirement under subparagraph (A)(ii), or reduce the threshold otherwise applicable under such subparagraph, with respect to an eligible hospital that is located in a rural or medically underserved area. . (b) Exclusion of payments from calculation of fee-for-Service costs under Medicare Advantage Section 1853(c)(1)(D)(i) of the Social Security Act ( 42 U.S.C. 1395w–23(c)(1)(D)(i) ) is amended by striking and 1886(n) and 1886(h) and inserting 1886(n), 1886(h), and 1899C .